Journal of Oral & Facial Pain and Headache, 04/2016

Aims: To assess drawings of pain sites and self-reported comorbid pains as a part of the biopsychosocial profiling of tertiary care referral patients with temporomandibular disorder (TMD) pain. Methods: A total of 135 consecutive patients referred to tertiary care for TMD pain participated. Patients drew all the sites where they had pain on whole-body pain drawings. Other assessments included self-reported comorbid pains in the head and body regions, the Finnish Research Diagnostic Criteria for TMD (RDC/TMD_FIN Axis II), and additional biopsychosocial and treatment-related variables. Patients were grouped into pain drawing profiles (localized, regional, and widespread) and the associations between these profiles and the biopsychosocial variables were statistically evaluated using Bonferroni adjusted P values and with logistic regression using SAS 9.3. Results: A total of 21% of the patients reported localized TMD pain, 20% reported regional pain (headaches and neckaches), and the majority, 59%, reported widespread pain (local/regional and multiple bodily pain sites). Patients with widespread pain profiles formed a heterogenous group in which 28.2% reported severe and 30.8% reported moderate pain-related disability. The widespread pain patients reported significantly higher levels of depression and somatization, lower levels of general health, more sleep dysfunction, decreased ability to control pain, and greater health care needs compared to patients with localized pain (P .05). Patients with regional pain profiles reported moderate scores on psychosocial functioning compared to the patients with localized or widespread pain. Conclusion: The majority of tertiary care referral patients with TMD pain reported comorbid pains. Pain drawings were found a useful adjunctive tool for screening and as a part of comprehensive biopsychosocial assessment and treatment planning for patients with TMD pain. Keywords: biopsychosocial assessment, comorbid pain, coping, health care use, pain, pain drawing, RDC-TMD Axis II

Aims: To investigate the prevalence of suicidal ideation (SI), depression, and anxiety in patients with a chronic temporomandibular disorder (TMD). Methods: The sample consisted of 1,241 consecutive patients diagnosed with muscle or joint pain, consistent with the Research Diagnostic Criteria for TMD (RDC/TMD), and assigned to one of three groups: Muscle pain (MM) group, joint pain (TMJ) group, and Mixed group. Variables of interest were specific demographics and psychometrics derived from the Symptom Checklist 90-Revised (SCL-90-R): three SI-related items, depression, anxiety, and Global Symptom Index score. Group comparisons were performed with χ2 tests and t tests; the level of significance was set at α = .05. Results: The mean (± standard deviation) age for the whole sample was 35.76 ± 12.6 years; 88.3% were women. The overall prevalence of SI items from the SCL-90-R was 8.4% for "thoughts of ending your life," 28.5% for "feeling hopeless about the future," and 20.5% for "having thoughts of death and dying." The overall prevalence of depression was 30.4% and overall prevalence of anxiety was 28.9%. Patients in the MM group reported the highest prevalence of SI. Patients in the MM group were significantly more likely to be depressed and anxious compared to patients in the TMJ (P .0001) and Mixed groups (P .0001). Conclusion: Elevated levels of SI, depression, and anxiety were reported in a chronic TMD population, especially in those with chronic muscle pain, compared to the general population. These findings emphasize the need for screening for suicidality and other comorbidities in TMD patients suffering from chronic pain. Keywords: anxiety, depression, prevalence, suicidal ideation, TMD

Aims: To evaluate the association between catechol-O-methyltransferase (COMT) gene polymorphisms and temporomandibular disorders (TMD), TMD pain, psychosocial impairment related to TMD, and postoperative pain. Methods: A total of 90 patients with a diagnosis of painful TMD and 92 matched controls were investigated for the presence of TMD, TMD pain, and psychosocial variables by the Research Diagnostic Criteria for TMD. In a prospective cohort study of 40 subjects who underwent extraction of at least one fully impacted mandibular third molar, subjects had 6 months post-surgery follow-up of postoperative pain. DNA extracted from peripheral blood was genotyped for three COMT polymorphisms (rs4680, rs6269, and rs165774) by real-time TaqMan method. The association between COMT polymorphisms and clinical variables was determined by calculating odds ratios (OR) and their 95% confidence intervals (CI). Results: Homozygous AA genotype and heterozygous variant A allele carriers (genotype AG/AA) for rs165774 polymorphism were associated with increased risk of TMD compared to wild type (wt) GG genotype (OR = 9.448, P = .006; OR = 2.088, P = .017, respectively). In addition, AA genotype was associated with increased risk of arthralgia (OR = 4.448, P = .011), myofascial pain (OR = 3.543, P = .035), and chronic TMD pain (OR = 6.173, P = .006), compared to wt genotype. AA genotype for rs6269 polymorphism was related to less postoperative chronic TMD pain (P = .025) and lower postoperative acute pain at the extraction site (P = .030). No associations with depression and somatization were observed. Conclusion: AA genotype of rs165774 could be a significant risk factor for the development of TMD and TMD pain, while AA genotype of rs6269 presents less postoperative chronic TMD pain and acute pain at a dental extraction site. Keywords: COMT, genetic polymorphisms, pain, temporomandibular disorders, third molar surgery

Aims: To evaluate the prevalence of self-reported bruxism and symptoms of temporomandibular disorders (TMD) and to investigate their association in academic and applied science university students in Finland. Methods: The data were gathered from 4,403 Finnish students included in the Finnish Student Health Survey 2012. The comprehensive questionnaire included five questions concerning bruxism and TMD symptoms. Bivariate associations between selfreported bruxism and TMD symptoms were evaluated using chi-square tests, and logistic regression model was used with age and gender as factors. Results: Sleep bruxism was reported by 21.0% of women and by 12.5% of men, awake bruxism by 2.0% of women and by 2.8% of men, and both sleep and awake bruxism by 7.2% of women and by 3.2% of men. TMD pain was reported by 25.9% of women and by 11.4% of men and temporomandibular joint (TMJ) pain on jaw movement by 9.6% of women and by 4.2% of men. Report of sleep bruxism increased the risk for all TMD symptoms in both genders. Among women, report of awake bruxism increased the risk for TMD pain and TMJ pain on jaw movement. Reporting stress as a perpetuating factor for TMD pain increased the risk for both sleep and awake bruxism in both genders. The logistic regression analysis (including age and gender) showed that report of sleep bruxism and/or awake bruxism was associated with TMD pain (Odds Ratio [OR] = 5.71; 95% confidence interval [CI] = 4.86-6.70), TMJ pain on jaw movement (OR = 4.49; 95% CI = 3.54-5.69), and TMJ locking (OR = 2.98; 95% CI = 2.17-4.10). Conclusion: Bruxism and TMD symptoms are frequent in Finnish university students. Selfreported bruxism is associated with TMD symptoms, confirming earlier findings. Keywords: bruxism, temporomandibular disorders, TMD, TMD pain, university students

Aims: To determine the prevalence and characteristics of burning mouth syndrome (BMS) in a Parkinson's disease (PD) population through a selfadministered, custom-made survey. Methods: A total of 218 surveys were collected during regular outpatient visits at two Movement Disorders Clinics in Montreal (Canada) and Toulouse (France) to gather information about pain experience, PD-related symptoms, and oral and general health. A neurologist confirmed the diagnosis of PD, drug treatment, Hoehn-Yahr stage, and Schwab & England Activity of Daily Living score. Data between groups were compared using the independent samples Mann-Whitney U test and two-sided exact Fisher test. Results: Data from 203 surveys were analyzed. BMS was reported by eight subjects (seven females and one male), resulting in a prevalence of 4.0% (95% confidence interval [CI] = 2.1-7.8). Five participants with chronic nonburning oral pain were excluded. PD severity and levodopa equivalent daily dose did not differ between non-BMS and BMS participants. Mean poor oral health index was higher in BMS compared to non-BMS subjects (49.0 vs 32.2 points, P .05). BMS manifested after PD onset in seven patients, did not occur on a daily basis in four, and always coexisted with restless legs syndrome. Conclusion: This survey yielded a low prevalence of BMS in PD patients, indicating no strong link between the two conditions. An augmenting effect such as that resulting from drug treatment in restless legs syndrome or sensory neuropathy cannot be excluded. Keywords: burning mouth syndrome, oral pain, Parkinson's disease

Aims: To measure the prevalence of cutaneous allodynia in Korean patients with migraine and to characterize the differential risks of migraine-associated factors and psychiatric disorders in its development. Methods: The study included consecutive patients with migraine who visited headache clinics at two tertiary care hospitals. Questionnaires including the 12-item Allodynia Symptom Checklist (ASC-12) and the Migraine Disability Assessment (MIDAS) were administered to the patients. The Mini International Neuropsychiatric Interview-Plus, Version 5.0.0 (MINI), was performed to diagnose current major depressive disorder (MDD) and current generalized anxiety disorder (GAD). To determine the predictive factors of cutaneous allodynia, a two-step logistic regression model was used. Results: A total of 332 patients were eligible for the study. Chronic migraine (CM) was present in 140 patients (42.2%). Current MDD and current GAD were identified in 73 (21.9%) and 59 patients (17.7%), respectively. Cutaneous allodynia was present in 48 patients (14.5%). Univariate analyses indicated that cutaneous allodynia was associated with female gender, CM, medication overuse headache, headache intensity, photophobia, phonophobia, MIDAS grade, current MDD, and current GAD. Multivariate analyses revealed that current MDD was the strongest risk factor for cutaneous allodynia (adjusted odds ratio [AOR] = 4.552; 95% confidence intervals [CI] = 2.300-9.007; P = .000), followed by CM (AOR = 3.666; 95% CI = 1.787-7.521; P = .000) and photophobia (AOR = 2.707; 95% CI = 1.340-5.469; P = .005). Conclusion: Korean patients with migraine have a low prevalence of cutaneous allodynia. Both depression and migraine-associated features are important factors in the occurrence of cutaneous allodynia. Keywords: allodynia, depression, frequency, migraine, risk factor

Aims: To assess the effects of application of an oxalic acid-based desensitizing agent before restoration of noncarious cervical lesions (NCCLs) with either a silorane-based or a methacrylate-based composite resin on decreasing the absolute risk and intensity of dentin hypersensitivity over the course of a 1-year follow-up. Methods: NCCLs in 31 patients (age range 24-66 years) were selected and randomly divided into four groups (n = 31 in all groups). In the Z250 and P90 groups, the restorations were performed with a methacrylate-based composite resin (Filtek Z250) and a silorane-based composite resin (Silorane P90), respectively. In the Z250 + OA and P90 + OA groups, the same composite resins were used, but an oxalic acid-based desensitizing agent (Desenssiv, SSWhite) was first applied. All NCCLs were evaluated before restoration (BR) and at 30, 60, 90, 180, and 360 days after treatment. Teeth sensitivity to evaporative and tactile stimuli was measured by a visual analog scale (VAS). The results were analyzed with statistical tools including Wilcoxon and Friedman tests for within-group comparisons and ANOVA and Bonferroni post hoc tests for between-group comparisons (P .05). Results: Reduction in dentin hypersensitivity was observed for all treatment groups; however, these reductions were more pronounced when oxalic acid was applied before restoring the NCCL (P .001). Complete elimination of pain was not achieved by any treatment modalities for the first 6 months; afterwards, in the groups that had received application of the oxalate-based desensitizing agent, the absolute risk of dentin hypersensitivity was significantly reduced (P .01). Conclusion: The restoration of sensitive NCCLs with composite resins reduces dentin hypersensitivity. This reduction is more pronounced if an oxalic acid-based desensitizing agent is applied prior to the restoration. In addition, its application reduces the absolute risk of dentin hypersensitivity after 6 months of treatment. Keywords: dental pain, dentin hypersensitivity, noncarious cervical lesion, oxalic acid, randomized clinical trial

Aims: To compare mechanical pain thresholds (MPTs) in the orofacial region assessed with two different approaches: with an electronic von Frey (EvF) device and with custom-made weighted pinprick stimulators. The test-retest reliability, variability of MPTs, and time duration of each test were also compared, as well as the ability of each test to create stimulus-response (S-R) curves. Methods: A total of 16 healthy volunteers participated. The MPT and S-R curve measurements were done with the two different techniques at three sites: on the skin of the right cheek (face), on the buccal gingival mucosa of the right upper premolar region (gingiva), and on the tip of the tongue (tongue). The same protocol was repeated 1 to 2 weeks later to determine test-retest reliability. Results: The MPT measurements with the EvF device were significantly faster (74.4 ± 20.8 seconds) than those with the pinprick stimulators (196.1 ± 33.0 seconds; P .001). The absolute MPT values obtained with the EvF device were significantly higher than the values obtained with the pinprick stimulators at all test sites (P .001). MPTs assessed with the EvF device showed higher reliability (intraclass correlation coefficient [ICC] = 0.77-0.94) than MPTs assessed with the pinprick stimulators (ICC = 0.57-0.84; P = .041). The reliability of the S-R curves was excellent for both methods with no significant differences between the methods (P = .403). Conclusion: This study indicates that MPTs tested in the orofacial region with the EvF device were significantly higher than MPTs tested with the pinprick stimulators. However, the EvF device can be used with higher reliability and less time consumption for assessment of MPTs in the orofacial region than the pinprick stimulator technique, and also allows comparable construction of S-R curves. Keywords: orofacial pain, quantitative sensory testing, reliability, somatosensory testing, variability

Aims: To examine the effects of local brain-derived neurotrophic factor (BDNF) produced after nerve injury on the functional regeneration of the damaged nerve. Methods: The inferior alveolar nerve was transected in adult male rats and 1 μg or 10 μg of BDNF antibody was administered at the injury site; a third group of rats received saline and a fourth group underwent nerve ligation. BDNF mRNA was quantified in the transected tissue and trigeminal ganglion by using realtime polymerase chain reaction (PCR). Head withdrawal thresholds following mechanical (tactile) stimulation (with von Frey filaments) of the mental region were measured for 3 weeks postoperatively. Electromyographic activity of the jaw opening reflex (JOR) was recorded from the anterior belly of the digastric muscle. Results: Within 24 hours, transection induced significant elevation of BDNF mRNA expression in the injured tissue (unpaired t test, P .01). The head withdrawal threshold to mechanical stimulation increased at 1 day after transection and then decreased (two-way repeated measures analysis of variance [ANOVA], P .001). At 2 weeks after surgery, the head withdrawal threshold was higher than before surgery in the group that received a higher dose of BDNF antibody (ANOVA, P .001), but not in the group that received a smaller dose (ANOVA, P > .05). No significant differences were observed in the latency or threshold of the JOR between saline- and antibody-treated rats (unpaired t test, P > .05). Conclusion: These results suggest that locally administered BDNF antibody neutralizes nerve injury-induced BDNF at the injury site and thus influences sensorimotor recovery. Keywords: jaw-opening reflex, neurotrophic factor, peripheral nerve injury, regeneration, withdraw reflex

Although the incidence of tetanus disease has radically declined in developed countries, both dental practitioners and oral and maxillofacial surgeons should be knowledgeable about its diagnosis since initial manifestations of the disease, such as trismus and dysphagia, are observed in the orofacial region. This study reports on a case of generalized tetanus diagnosed in a middle-aged man. Before the tetanus diagnosis, the patient had sought medical advice from seven different health care professionals, including a dentist and an oral and maxillofacial surgeon. The patient reported trismus and dysphagia as his main complaints. The suspicion of tetanus emerged from the patient's manifestations in conjunction with his history of trauma and his agricultural occupation. The patient underwent successful treatment including administration of muscle relaxants, antibiotics, and booster vaccination doses of tetanus toxoid as well as a tracheostomy and aided mechanical ventilation. This case report highlights the significance of taking a meticulous medical history, thoroughly performing a physical examination, and systematically assessing orofacial signs and symptoms. Keywords: diagnosis, lockjaw, tetanus, treatment, trismus