Incidence of Cervical Disorders in a T.M.D. Population.

M. PADAMSEE, N. MEHTA, A. FORGIONE, S. BANSAL

(Tufts University School of Dental Medicine, Boston, MA USA).

A study was conducted to assess the incidence of cervical pain and dysfunction in a temporomandibular dysfunction (TMD) population and to examine the association of cervical spinal dysfunction (CSD) with A) history of trauma, B) bruxism or C) dental treatment as possible etiologic factors. 250 patients (82% female) reporting sequentially to the Tufts Gelb TMD and Orofacial Pain Center were selected as subjects. The above etiologic factors were considered singly or in combination based on verbal identification of an immediate correlation to the time of trauma and emergence of symptoms. Dental treatment was taken into account only when the patient reported emergence of symptoms immediately following the respective dental procedures. Bruxism was considered only when confirmed by personal knowledge or by report of a significant other. 70.8% of the sample (n=177) had TMD associated with CSD while only 29.2% (n=73) had TMD without CSD. Of patients with history of trauma, 38% had TMD associated with CSD, while only 6% had TMD without CSD. (Chi Square- 16.8, df =1, p<.001). Bruxism was involved in 71% of the sample population (74% in TMD, CSD patients and 64% in the TMD only patients). Bruxism as a single, causative etiologic factor was found with 22% of entire sample. Of the entire population of patients 32% (n=82) symptoms were reported immediately following dental treatment. The data indicate that CSD is associated with TMD more frequently (70%) than TMD alone (29%) in an oralfacial pain population. When a history of trauma is present, CSD is associated with TMD more often (38%) than not (6%).

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Effect of Appliance Therapy on Specific Symptom Sites of TMD.

E. ABDALLAH, A. ABOUSHALA, N. MEHTA AND A. FORGIONE

(Tufts University School of Dental Medicine, Boston, MA USA).

A retrospective study was designed to evaluate the effect of flat plane, intraoral appliances on the number of sites of specific Temporomandibular Disorder (TMD) symptoms.  Fifty-five subjects were selected from patients visiting the Gelb Craniomandibular and Orofacial Pain Center at Tufts University School of Dental Medicine.  The criteria of selection were: 1) No physical therapy or chiropractic treatments prior to or during the four visits, 2) No muscle relaxants, psychotropic or pain medication or any active treatment for their presenting symptoms and 3) Treatment having consisted of only a full coverage, flat plane, lower appliance. Symptom sites were recorded on the day of appliance insertion and on the fourth visit during an eight-week period. Symptom sites for each of four areas of the body studied were given a maximal score of 100 according to the following weighting: 1) Headache (29 of 55 subjects) frontal = 25, occipital = 25, right temporal = 25 and left temporal =25; 2) Neck complaints (24 of 56 subjects) stiffness/pain = 50 and tightness = 50; 3) Joint sounds (24 of 55 subjects) right side = 50; and 4) Joint pain (28 of 55 subjects) right side = 50, left side = 50.  Wilcoxon Signed Rank Tests showed a significant reduction in all TMD symptoms sites; 1) the number of headaches sites in 29 subjects showed a reduction of 65% (p<0.001), 2) neck symptom sites in 24 subjects reduced 57% (p<0.001), 3) the number of joint sound sites in 24 subjects reduced 74 % (p<0.0003) and 4) the number of joint pain sites in 28 subjects reduced 71% (p<0.0001).  Results suggest that the sole use of flat plane, appliance therapy is effective in reducing the number of specific head, neck and TM joint symptom sites in TMD patients.

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Effect of Vertical Dimension and Mandibular Position on Sternocleidmastoid Strength

H. AL-ABBASI, N. MEHTA, A. FORGIONE and E. CLARK

(Tufts University School of Dental Medicine, Boston, MA USA)

 

Forgione, et al. (J Craniomandib Pract 10: 13-20, 1992) found isometric strength (IMS) to increase in deltoid muscles with a Bite Elevating Appliance (BEA) set to functional criterion.  To examine the effect of vertical dimension (VD) and mandibular position on IMS of the sternocleidomastoid muscles (SCM), 8 females and 7 males, presenting with deep bite and loss of VD were selected. Horizontal force was applied to the forehead by a hand held strain gauge. Each subject (S) resisted maximally as increased force was applied over a 3-second period until neck resistance yielded. (Peak Resistance, PR). All Ss were at least 3 lbs. Stronger at PR with teeth disoccluded than when biting in habitual (H). Mean PR disoccluded was 33.6% greater than in H (t_14df =9.29, p<0.0001). Four acrylic BEAs were constructed for each S. The first increased the VD in habitual (EH) to peak resistance of the deltoid muscles, right and left as in Forgione, et al. This position was transferred to an articulator and three other BEAs were constructed as this VD: 1) Edge to Edge (EE), 2) Retruded (R) and 3) Lateral Shift (LS), shifting the mandible 1mm to the left. Each subject was tested twice at random in each of 8 positions: H, EE, R, and LS, with and without BEAs. A 2 level factorial, within subject, ANOVA showed a significant main effect, the mean of biting at the elevated VD, 27.17 lbs. being significantly greater (F_{1 df} = 75.94, p = 0.000) than biting without a BEA (21.73 lbs.). Positions showed a significant AxB interaction, F_{3 df} = 3.26, p=0.03. Without a BEA, Ss in H were significantly weaker than in R and EE but not LS. With the BEA, the same Ss in BH and EE were significantly stronger than in R but not LS. Biting at an elevated VD increased SCM isometric the most. These findings reinforce and extend earlier findings of bite related increased isometric strength in parts of the body other than the stomatognathic system.

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SCL-90 Scores and Symptoms of Tinnitus-TMD, TMD Patients and Controls.

G. MALONEY, E. MATIGNON, N. MEHTA and A. FORGIONE

(Tufts University of Dental Medicine Boston, MA USA)

 

Tinnitus is occasionally reported by Temporomandibular Disorder (TMD) patients. In order to assess the presence of tinnitus, the SCL-90 and a list of 30 somatic complaints were used to compare 50 TMD patients with tinnitus (TTs), 50 TMD patients without tinnitus (NTTs) and 50 non-patient controls (NPCs) in a retroactive study. Records of TTs were selected from 200 patients who had been treated at the Gelb Craniomandibular Orofacial pain Center. NTTs were randomly selected from the same population and NPCs were chosen from the students, faculty, and staff of the dental school. Mann-Whitney U tests were performed on raw scores of each of the nine dimensions of the SCL-90. TTs were significantly greater than NTTs on all dimensions except Obsessive-Compulsive, Interpersonal Sensitivity, and Hostility and greater than NPCs on all dimensions except Obsessive-Compulsive, Interpersonal Sensitivity, Hostility, Phobia and Paranoia. Scores on the 30 symptom list were available for only 36 tinnitus patients, so 36 were randomly selected from the 50 NTTs. Mann-Whitney U (U=135.5, Z_{cor for Ties} =4.66, p=0.0014) showed that TTs as a group (Median=12.75) reported significantly more symptoms than NTTs (Median=5.9). With respect to specific symptoms, only three were significantly greater than NTTs: Pressure in eye, Neck Pain and Difficulty Swallowing. No NTT symptoms were greater in TTs. TMD patients with tinnitus exhibit SCL-90 scores indicating greater emotional stress than TMD patients not reporting this problem. In addition, those with tinnitus generally exhibit a higher frequency of somatic complaints. These findings suggest that TMD patients with tinnitus may require broader treatment including psychological, to help cope with the greater physical and emotional stress.

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Relationship Between TMD Multiple Somatic Complaints and SCL90 Depression Scores.

M. FITZGERALD, N. MEHTA, and A. FORGIONE.

(Tufts University School of Dental Medicine, Boston, MA USA)

 

Many TMD patients experience a variety of non-specific symptoms in addition to pain and mandibular dysfunction. To study the prevalence of multiple somatic complaints in patients with TMD and study its relationship to SCL-90 depression scores, three measures of multiple somatic symptoms were selected. Using cut-off points from the Research Diagnostic Criteria Report (Dworkin and LeResche, J Craniomandib Disorders, v. 6: no. 4, 1992), above average values were determined for 1) the somatization scale (SOMA) and 2) the somatization scale with only non-pain items (SOMANP). In addition, a scale measuring multiple pain sites (MULPAIN) was used. 46 records were selected at random from the patient population of the Gelb Craniomandibular/Orofacial Pain Center and analyzed. 56.5% of the patients exhibited above average values for SOMA, 30.4% for SOMANP and 37% of the patients had 2 or more pain on MULPAIN. Scores on the Depression Scale were significantly correlated to SOMA (Pearson r= 0.60, p=0.00005), SOMANP (r=0.68, p=0.00005) and MULPAIN (r=0.54, p=0.0001). After controlling for possible confounding effects of age, sex, initial pain level, duration of the problem, diagnosis of cervical condition and history of whiplash or trauma by multiple regression analysis, the positive correlation with depression scores remained significant for the SOMA (t_df=39 5.02, p<0.00001) and SOMANP (t_df=39 6.17,p<0.00001) but not for MULPAIN (t_df=39 1.62, p=0.116). The results indicate that approximately one third of TMD patients reported non-pain symptoms and multiple pain sites. Non-pain symptoms (SOMANP) were found to be as strongly correlated to depression as a mixture of pain and non-pain symptoms (SOMA).

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SCL-90 and Pain Scores Before and After TMD Biteplate Therapy.

A.      ALAMMAR, N. MEHTA, A. FORGIONE and E. CLARK

(Tufts University School of Dental Medicine, Boston, MA USA)

 

Use of the Symptom Check List (SCL-90) is increasing in the research and treatment of Temporomandibular Disorders. To determine whether the dimensions assessed tend to be indicators of enduring tendencies or short term characteristics associated with pain, the SCL-90 and a 10-point numerical graphic analogue pain scale were administered to 50 TMD patients (TMDs) selected at random at the Gelb Craniomandibular and Orofacial Pain Center and 50 non-patient controls. TMD patients were treated by intraoral appliance therapy with regular adjustment visits. Three months after insertion, tests were readministered to both groups. Median pain level for TMDs (5) decreased significantly to (2) according to the Wilcoxon Signed Rank Test (WRST), p<0.0001. The median pain level for controls (1) remained unchanged (1), WRST p=0.45). WRSTs performed on SCL-90 pre and post raw scores of TMDs showed significant reduction in all dimensions except Phobic Anxiety. Pre and post scores for controls were stable. The SCL-90 profile of the 42 TMDs who showed pain reduction was no different from that of the control group. Reduction in pain in all TMDs was significantly correlated with reduction in all psychological dimensions except Paranoid Ideation. No positive correlations were found for controls. The reductions of pain has broad psychological impact and the SCL-90 was found to be sensitive to it. These findings suggest strongly that with pain patients, scores on the majority of SCL-90 dimensions be considered part of a reactive pattern to pain. In the presence of pain, SCL-90 scores cannot serve as a valid indicator of enduring psychological tendencies. Without considering the transitory, score-elevating effect of pain, the origin of the pain may, in whole or in part, be attributed to incorrectly to the dimensions elevated.

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Physical (Axis-1) Changes Related to TMD Bite Appliance Therapy.

M. PADAMSEE, N. MEHTA, G. WHITE, A. FORGIONE and

E. CLARK (Tufts Univ. School of Dental Medicine, Boston MA, USA).

 

This study was designed to compare the effects of two types of appliance, flat plane (FP) and anterior repositioning (AR) on selected subjective and objective dimensions from Research Diagnostic Criteria (Cranio, 6;4, 1992).  Twenty patients visiting the Gelb Craniomandibular/ Orofacial Pain Center were selected in order of appearance and assigned randomly to two groups. The age range was 18-45 years.  One group was fitted with a FP and the other an AR.  Prior to insertion, a 10-point visual analogue scale (VAS) was administered to rate headache, joint clicking, and joint pain and ear stiffness. Patients were then tested for 1) unassisted maximum interincisal opening, 20 excursions, 3) opening click and 4) joint sounds on excursion. After 2 months, the VAS was readministered and the patients retested.  Two factor, mixed factorial ANOVAs were performed on all testes except click on opening and joint sounds on excursion.  Headache (F_df=1= 5.52, p=0.024), subjective rating of clicking (F _df=1=27.75, p<0.0001) and joint pain (F _df=1=12.39, p=0.001) reduced significantly in both FP and AR. Ear stuffiness did not change. In contrast, the mean of the AR increased significantly (33.35 mm to 41.6 mm) for interincisal opening (p<0.001) while FP did not. Also, for excursions, there was a significant main effect for sequence (F _df=1 =50.51, p=0.0001) and group sequence interaction (F _df=1=13.32, p=0.0008). Mean FP increased 1.125 mm (P<0.05>0.02) while mean AR increased 3.5 mm (p<0.001).  While joint sounds on excursion did not differ (Fisher Exact=0.0518), click on opening decreased significantly to zero for AR patients (Fisher Exact=0.0139). While both appliances significantly reduced subjective symptoms, AR was more effective in reducing Axis-1 objective measures.

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Quantitative Assessment of Posture and Cervical Function in CMD Patients.

H. WU, N. MEHTA, A. FORGIONE, E. CLARK, W. ELBERMANI

(Tufts University, Boston, MA USA)

 

This study was designed to find whether there is any difference of head posture and neck function between patients with craniomandibular disorders and asymptomatic women.  40 female volunteers between 18 and 55 years of age joined the study: 20 CMD patients with chronic orofacial pain and frequent headache (equal or more then three times a month) and 20 age-matched asymptomatic women.  Subjects in both groups had no history of physical trauma on the head and neck area in recent ten months.  In present study, 70% (14) of twenty CMD patients had more than one headache per week, the mean frequency of headache in CMD patient was 8.83 per month. By using computer-assisted video-digitizing posture analysis (VDPA) system which can provide life-sized, 640dpi X 480dpi resolution, true color images allowing hand digitizing, the head posture as well as full range of neck motion in three dimensions were recorded and computed. The validity of the VDPA system has been tested by repeated measurements of eleven angles and one linear distance. An extremely strong correlation was present between the readings from goniometer and VDPA system (r=1.000, P<0.00001).  The mean difference between ten repeated measurements was 0.12.  A highly significant difference (P<0.001) of eye-tragushorizontal angle was found between two groups (48.56"3.44, 53.73"4.82) as tested by Student’s test. The CMD patients showed a more forward head posture.  The CMD patients also had much less mean cervical movement in all three dimensions including bilateral side bending, rotation, and cervical extension/flexion (R:28.00 "5.42, L: 33.31 "6.05, R:75.12 "21.36, L: 74.63 "19.74, E: 20.69 " 7.65, F: 27.55 " 8.08) than the asymptomatic group ( R: 44.99 "5.07, L:45.48 " 4.05, R: 90 "2.60, L:90 "2.30, E:32.22 "5.62, F:47.35 " 6.03).  These differences were significant (P<0.001) as tested by Student t-test.  The results strongly indicated that most of CMD female patients with frequent headache syndrome had cervical dysfunction.  Thus, the evaluation of head posture andTufts University School of Dental Medicine, Boston, MA USA). cervical function are recommended.

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Effect of Repositioning and Flat Occlusal Splints on Masticatory Muscle Tenderness.

M. PADAMSEE, N. MEHTA, G. WHITE, R.E. CLARK, and A. FORGIONE. (Tufts University, Boston, MA USA).

To compare the effects of Flat Occlusal (FO) and Anterior Repositioning (AR) splint therapies for TMD, 20 (18 female and 2 male) patients were assigned randomly to 2 groups: FO or AR. Prior to splint insertion, each patient was administered a 10 point visual analog scale (VAS) to measure severity of symptoms. This scale was especially designed for the present study. Patients rated degree of 1) earache, 2) ear stuffiness, 3) headache, 4) facial pain and 5) neck (pain/stiffness). At this time, masticatory muscles were palpated according to the Research Diagnostic Criteria for TMD (Dworkin and LaResche, 1992) and patients scored levels of discomfort on the VAS. Patients were examined and evaluated every 2 weeks and after the 8^th week the same evaluation was repeated. For all sites, a mean score was obtained by averaging right and left scores. Wilcoxon T tests revealed that patients in the FO group reported significant reduction in earaches (p=0.03), whereas the AR group reported significant reduction in earache (p= 0.04), ear stuffiness (p=0.04), headaches (p=0.02), facial pain (p=0.02) and neck stiffness (p=0.02). Mann-Whitney U tests showed that pre-experimental palpation scores were not significantly different between AR and FO groups. Responses to palpatory tenderness over 10 muscle sites after 8 weeks showed significant reduction in all AR muscle sited and only 6 of 10 FO muscle sites (Wilcoxon T tests, P<0.05). Mann-Whitney U tests comparing AR to FO showed in 4 of 10 sites that AR muscle tenderness scores were significantly lower that FO in the following sites: 1) back of temple (p=0.001), 2) middle temple (p=0.004), 3) front of temple (p=0.01) and 4) lateral pterygoid (p=0.02). While both appliances reduced reported symptoms, the AR splint was significantly more effective in reducing temporalis and lateral pterygoid muscle palpation tenderness.

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SCL-90 Scores of Treated TMD Patients and Normal Contols

A.      FORGIONE, R. BAHRAM, N. MEHTA and E. ABDALLAH

(Tufts University School of Dental Medicine, Boston, MA USA).

 

Thirty one consecutive patients, attending the Gelb TMD Orofacial Pain Center, who had received at least three months of biteplate treatment were administered a second SCL-90 and 10-point Visual Analog Pain Scale. 30 females and 1 male comprised the patient. 50 non-patient controls were recruited from the students and staff of tufts Dental School. Over the period of treatment, general pain level reduced significantly (Wilcoxon Signed Rank Test [WSRT], P=0.00001) from a median of 6 pre-treatment to a median of 3 after the treatment period. During the same period pain pre-, median=2.01, was no different form pain post, median=1.6 (p=0.45). WSRTs showed that with the exception of Phobia (p=0.07), scores on all dimensions decreased significantly: 1) Somatization, p=0.03, 2) Obsessive-Compulsive p=0.007, 3) Interpersonal Sensitivity, p=0.003, 4) Depression, p=0.015, 5) Anxiety, p=0.001, 6) Hostility, p=0.018, 7) Paranoia, p=0.038, 8) Psychoticism, p=0.02. For controls, there was no difference between pre- and post-treatment scores on all dimensions except Psychoticism (p=.048). TMD patients were then divided into pretreatment high pain (>5) and low pain (5 and lower) groups of 18 and 13 respectively. Both groups reported a significant reduction in pain from the start of therapy: High pain p=0.0002 and low pain 0.0185. WRSTs performed on the scores of low pain patients showed a significant reduction in only the Hostility scores, p=0.0145. The high pain patients reported a significant reduction in all dimensions except Somatization, Hostility and Paranoia. Selecting specific items of the Somatization dimension responses of the group of 31 patients showed significant reduction in the headache item (p=0.0157), the muscle pain item (p=0.002), the numbness item (p=0.0157) and the back pain item (p=0.033). Biteplate therapy for TMD reduces reported stress levels significantly in 9 of 10 dimensions of the SCL-90. Analysis of the high pain patients indicates that the greater reduction in these patients may overshadow the smaller changes of the low pain group.

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SCL-90 Scores of TMD Patients 6 and 12 Months Following Initiation of Treatment.  
R. BAHRAM, N. MEHTA, A. FORGIONE and E. ABDALLAH

(Tufts University School of Dental Medicine, Boston, MA USA).

 

This study was designed to assess the change in psychological variables following biteplate therapy in the treatment of Temporomandibular Dysfunction. The SCL-90 (Derogatis) is a self-report test which assesses 9 psychological dimensions. Thirty-one patients of the Gelb Craniomandibular/Orofacial Pain Center were selected at random form 150 patients treated in a six-month period. The SCL-90 along with a 10-point Visual Analogue Scale to measure pain were administered before treatment and at end of treatment (6 months after treatment began). Then 6 months later, the inventories were mailed to the patients. Eighteen responded to the 6-month follow up. Their responses were analyzed with Wilcoxon Signed Rank Tests (WSRT). General pain decreased significantly from initial levels over the first 6 months (WSRT, p=0.0007) and 6 months later the decrease was maintained (WSRT, p=0.0023). The pain levels of the two periods were no different (p=0.5895). Two psychological dimensions showed significant reductions over the assessment periods. Although depression did not show a significant reduction six months after treatment began. (WSRT, p=0.1989), it did decrease a significant degree from pre-treatment level by the one-year period (WSRT, p=0.0113). Likewise, hostility did not decrease significantly by 6 months after start of treatment (WSRT, p=0.1850) but did reduce to a significant level by one year following initiation of treatment (WSRT, p=0.0294). None of the other psychological dimensions showed significant changes for the periods assessed. The results indicate that a significant reduction in pain results from biteplate therapy after 6 months of treatment and this reduction from pre-treatment level persists six months after termination of treatment. The appearance of significant reductions in depression and hostility 6 months after termination argues for follow-up testing because impact on psychological dimensions may not become manifest until some time after treatment is terminated.

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Maxillomandibular Relationship in TMD Patients Before and After Short Term Bite Plate Therapy.
A. FU, N. MEHTA, A. FORGIONE, E. CLARK, C. HAYES, G. KUGEL and E. ABDALLAH.  (Tufts University of Dental Medicine, Boston, MA USA).

 

The purpose of this study was to assess the maxillomandibular relationship in temporomandibular disorder (TMD) patients, before and after short term flat bite plate therapy, to determine whether there is transverse shift of the mandible toward the frenel midline. Twenty subjects, 17 females and 3 males (mean age = 38 years + 12.2) from the patient population attending the Gelb Craniomandibular and Orofacial Pain Center at Tufts University of Dental Medicine were selected based on the Research Diagnostic Criteria for TMD. Thirteen subjects had a diagnosis of myofascial pain (RDL I.a), while7 subjects had at least one diagnosis of disc displacement with reduction (RDC II.a). Impressions were taken, and diagnostic casts were fabricated for all subjects. A Vinyl Polysiloxane Plaster bite registration material (Regisil PB ä Cartilage System) was used to record the maxillomandibular relationship, both in full bite as well as in first contact. The casts were then mounted on a Denar condylartracing articulator, using the bite registration material, and the maxillomandibular relationship evaluated using the Centric Check System. The frenel attachment to the upper and lower gingiva was used as a reference to evaluate mandibular shift. At the initial visit, all subjects showed a mandibular shift, with 9 subjects shifting to the left side and 11 shifting to the right. Symptom questionnaires were used to assess associated pain and discomfort. Bite plate therapy was provided to the patient for 4 weeks, after which a second set of bite registrations were taken and symptom questionnaires provided. A Binominal test was performed to evaluate the rate of occurrence of mandibular shift. All subjects shifted to the frenal midline position, following short term bite plate therapy, regardless of the original position right or left (Binominal p<0.001). The results of this study indicate that the mandible will shift toward the frenal midline position after short-term bite plate therapy.

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Self –Reported Temporomandibular Joint Dysfunction Symptoms in 220 American Dental Students. 
O. MARK, N. MEHTA, A. FORGIONE.

(Tufts University School of Dental Medicine, Boston, MA USA).

 

This study assessed the prevalence of Temporomandibular Joint (TM) Dysfunction in students at Tufts University of Dental Medicine. Three classes were administered in a 12 item questionnaire requiring a yes/no response to questions about discomfort and dysfunction of the TM Joints and associated muscles. Of 125 forms administered, Class of 1998 (’98) returned 105 (mean age=26.8), Class of 1999 (’99) 115 (mean age=25.1) and Class of 2000 (’00) 100 (mean age of 23.7). Each class had a ratio of approximately 60 males to 40 females. The number responding to at least one item was 65 for ’98, 76 for ’99 and 45 for ’00. There was no difference in sex response. Generalized chi square (chi²) showed a significance difference in the responses of the three classes (chi²_df2=10.15, p<0.01). Separate Yeates corrected 2x2 chi² tests showed that the number responding in ’98 was no different from in ‘99(chi²=0.25) while the number responding in both ’98 (chi²=4.91, p<0.05) and ’99 (chi²=8.40, p<0.01) were significantly larger than in ’00. Because of this the results of ’00 could not be pooled with those of ’98 and ’99. Of 220 students, 43% reported clenching and grinding, 30% reported noises in the joint, 21% sore muscles of mastication, 13% frequent headaches, 11% difficulty and/or pain chewing or talking, 10% jaw “locking or going out” and 7% difficulty and/or pain on opening. Students who answered at least one of the 12 questions were requested to rate pain/discomfort on 11, 10-point Visual Analogue Scales (VAS) each locating a pain site. Of the 220 students, 24% responded to TMJ clicking (mean VAS=4.3), 18.9% to neck pain (mean VAS=4.2), 16.9% to headaches (mean VAS=4.7), 13.8% to TMJ pain (mean VAS=3.7), 13.3% to pain in teeth (mean VAS=3.2), 8.9% to face pain (meanVAS=3.6). The prevalence of symptoms is somewhat higher than reported in Swedish dental students and young men of comparable age. The observations in this, the first of a series of students to track symptoms over each year of dental school, suggest that dental schools screen students for TM Dysfunction.

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Vertical Dimension’s Effect on Sternocleidomastoid Strength in Complete Denture Patients.
A. ABOUSHALA, N. MEHTA, G. KUGAL, R. CHAPMAN, R.E. CLARK and A. FORGIONE (Tufts University School of Dental Medicine, Boston, MA USA)

.

 

Al-Abbasi et al. (IADR Abstracts, vol. 74, #997, 1994) found isometric strength (IS) of the sternocleidomastoid muscles (SCMs) increased with bite elevating appliances in deep bite subjects. This study examined the effect of vertical dimension on the IS of SCMs of complete dentures patients. Ten males and 7 females (mean age=58.7, SD=10.89) were seated upright and instructed to resist maximally a horizontally applied force provided by a hand-held strain guage. A headrest was placed 2 inches from the occiput to prevent hyperflexion of the neck. Steadily increasing pressure was applied to the forehead until resistance was overcome. The force required to overcome the resistance was recorded as kilograms peak resistance (PR). PR was recorded under 6 conditions: 1) mandibular rest position (RP), biting 2) without dentures, 3) on existing dentures, 4) on blocks placed over the premolar to molar region which increased the vertical dimension of occlusion (VDO) 2 mm, 5) 6mm and 6) 10mm. IS did not increase monotonically as VDO was increased from 2 to 10 mm above denture height. In some cases IS decreased as 10mm. However, in no case did IS decrease at 2mmabove the denture VDO. Therefore, the maximum IS under 2, 6 and 10 mm was selected for the overall analysis. Two way ANOVA for repeated measures showed the mean PR biting on dentures (4.45 kg, SD=1.26) was not different from that of RP (4.69, SD=0.99) and both were significantly greater (p<0.001) than without dentures (2.93 kg, SD=0.83). The mean IS of the SCMs of the maximum PR (6.97 kg, SD=1.42) was significantly greater than RP and biting with and without dentures (p<0.001). The results indicate that, altering the VDO has a significant effect on the IS of the SCMs. The IS of the SCMs in this sample was not maximized at the denture VDO.

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Effect of Graded Increaes in Vertical Dimension on Cervical Flexor Strength.

A.     CHAFKA, N. MEHTA, G. KUGEL, C. HAYES, A. FORGIONE

(Tufts University School of Dental Medicine, Boston, MA USA).

 

The effect of vertical dimension (VD) on maximizing isometric deltoid strength (IDS) has been researched in subjects with deep overbite. However, vertical dimension has been determined in these studies functionally using the Isometric Deltoid Press (Forgione et at CRANIO 10 (1): 13-20, 1992). In this study vertical dimension of occlusion was increased, 2, 4 and 6 mm using lower acrylic mouthplates. Twenty normal females, mean age 31 yrs., sat erect in a dental chair and were instructed to bite and either resist to their maximum ability a horizontal force applied to the forehead or a vertical downward force to the wrist of the first one then the other extended arm. This procedure was repeated in normal occlusion and while biting on mouthplates which raised the VD 2, 4 and 6mm. The order of testing was counterbalanced, with one investigator inserting the appliance while another performed the muscle testing. Horizontal and downward pressures were applied by a hand-held stain guage. Peake resistance was measured twice in each condition and averaged to produce a peak isometric strength (PIS). Mean strongest PIS for each site tested was compared to each subject’s PIS while biting in habitual occlusion. PIS of cervical flexors with the elevated bite (mean=11.97Kg) was significantly greater (p<0.01>0.001) than that for habitual occlusion (9.63Kg). PIS for right and left deltoids did not differ but mean deltoid PIS in the elevated condition (8.60Kg) was significantly greater (p<0.001) than biting in habitual occlusion (6.6Kg). In the peak condition, cervical flexors increased 24% and deltoids increased 30%. Strength was measured for habitual occlusion after occlusion after all trials were administered and were found not to differ from pre-experimental levels indicating that fatigue was not an important factor. In an earlier study, Hart et al (JOSPT 3 (2):57-61, 1981) was unable to show significant differences when the vertical dimension was raised gradually. However, his dependent variable was isokinetic strength. In earlier publications we have suggested that the strength phenomenon is more salient in isometric strength than isokinetic. Isometric strength of the cervical flexors and deltoids increase significantly when vertical dimension of occlusion is increased in deep overbite subjects.

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The Effect of Pain Reduction On The Quality of Life (SF-36) In Orofacial Pain Patients. 
S. ESTRADA, N. MEHTA, A. FORGIONE, C. HAYES, E. ABDALLAH. (Tufts University School of Dental Medicine, Boston, MA USA).

 

The aim of this study was to determine the effect of pain reduction on the quality of life in pain patients. The Visual Analog Scale (VAS) was used to measure specific pain items (earache, TMJ pain, Headaches, neck, upper and lower back pain), whereas the Short Form 36 (SF-36) was used to measure the quality of life through its 8 items: Physical functioning (PF), Role Physical (RP), Bodily pain (BP), General Health (GH), Vitality (VT), Social functioning (SF), Role Emotional (RE) and Mental Health (MH). Forty-four TMD and Orofacial pain patients (F=36, M=8, age =35"13) with no history of physical disability of psychological problems were selected. Thirty control subjects (F=14, M=16, age 35"10) were selected randomly from the faculty and staff at the university. Patients and controls were requested to complete the VAS and the SF-36 forms at the initiation of the stuffy and 3 months later. All patients had conservative treatment using intraoral appliance therapy with/out physical therapy modalities for the period of the study. The Wilcokon signed rank test was used to compare between pre and post treatment pain and SF-36 scores for patients and controls. There was a significant reduction (p<0.05) in all pain items for patients, whereas there were no statistically significant changes (p<0.05) for controls. SF-36 results showed a significant increase (p>0.05) in all items for patients with the exception of GH and RE. There were no significant changes (p>0.05) in any of the SF-36 items for controls except for an increase in social functioning (p<0.05). the Spearman’s rhe was used to determine pre and post-treatment correlations between pain and SF-36 items. There were significant pre-treatment (p<0.05) as well as post-treatment (p<0.05) correlations for 1) TMJ pain and PF, RP, 2) face pain and VT, MH, 3) u/back and all SF-36 items except RE, 4) 1/back and PF,VT.  These results indicate that the reduction of pain in TMD and orofacial pain patients is associated with an improvement in patient’s well-being, quality of life and perception of health as measured by the SF-36.

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SF-36 Scores of TMD, Chronic Back Pain, Combined Pain Patients and Controls.
N. MEHTA, A. FORGIONE. (Tufts University of Dental Medicine, Boston, MA USA).

 

The SF-36 is a widely used survey to assess health status from the patient’s point of view. This patient based, generic health status assessment survey obtains patient’s assessments of their functioning and well-being and perception of their general health. It serves as a disability measurement instrument in 29countries(Ware, J.E. & Sherbourne, C.D., Medical Care, 30:473-483; 1992). The dimensions measured are 1) Physical Functioning, PF, 2) Role Physical, RP, 3) Body Pain, BP, 4) General Health, GH, 5) Vitality, VT, 6) Social Functioning, SF, 7) Role Emotional, RE or the effect on usual role due to physical or emotional health, 8) Mental Health, MH. It was of interest to compare the responses of pain patients seeking treatment for TMD, back, and combined TMD and back pain to determine whether their limitations were similar and to compare these scores with those of asymptomatic controls. The SF-36 scores of four groups of 30 subjects each were analyzed with the Kruskal-Wallis ANOVA by ranks for independent samples. A separate ANOVA was performed for each of the 8 dimensions. Mann-Whitney U tests were used to compare scores within each dimension. With the exception of VT, control scores were significantly higher, p<0.01 (greater function, least limitation) than those of the other three groups and chronic back pain scores were significantly smaller than all other groups. TMD and combined TMD/back pain scores were both significantly smaller than the scores of controls and significantly greater than those of chronic back pain patients. The difference in the presence of the back pain factor is probably due to the chronicity of the back pain patients who were specifically diagnosed opposed to the TMD being the presenting symptom in the combined pain group. TMD patients tend to suffer impairment in functioning that is intermediate between asymptomatic patients and chronic back pain patients. The impact of TMD on dimensions of functioning is clearly revealed I the scores of the SF-36 suggesting is as an important diagnostic instrument for disability in the treatment of TMD and the assessment of treatment outcome,

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Effect of Intra-Oral Appliance Therapy in Chronic Tension Type Headache with Disorder of the Pericranial Muscles.
Y. ABOU-ATNE, N. MEHTA, A.FORGIONE. (Tufts University School of Dental Medicine, Boston, MA USA).

 

The effect of intra-oral appliances in Chronic Tension Type Headache (CTTH) patients with disorders of pericranial muscles was studied. Ten females were found who fulfilled the International Headache Society criteria for CTTH (mean age: 34 years, range 21-55). All were using medication, which was reported ineffective in controlling their headaches. Before treatment, weekly average of CTTH frequency was 4.8 days and intensity 5.0 on a 0-10 numeric visual analog scale. Treatment consisted of two intra-oral, full coverage hard resin appliances: a mandibular appliance for days and a maxillary appliance for sleep.  Muscle tenderness was measured by manual palpation and algometers. Fourteen pericranial muscle and tendon sites (seven sites on each side) were measured 1) one week before inserting the appliances (pre-insertion1), 2) the day of insertion (pre-insertion2) and 3) seven weeks after insertion (post insertion). A CTTH questionnaire was given on each visit. All patients were CTTH free at the end of the experiment. Total pain threshold (TPT) algometer measurements pre-insertion1 (10.6Kg/cm²) versus pre-insertion2 (11.5Kg/cm²) did not differ significantly. There was a significant difference in TPT algometer measurements between pre-instertion1 (10.6Kg/cm²) and post-insertion (14.0Kg/cm², p<0.01) and also between pre-insertion2 (11.5Kg/cm²) and post-insertion (14.0Kg/cm², p<0.05). TPT palpation measurements pre-insertion1 versus pre-insertion2 did not differ significantly (p>0.05), while pre-insertin1 versus post-insertion and pre-insertion versus post-insertion differed (P<0.01). A significant correlation was found between algometer measurements and palpation                         

(r = -0.699, p<0.01), palpation and intensity of the headaches (r = 0.659, p<0.01), palpation and frequency of the headaches (r = 0.465, p<0.05), and intensity and frequency of the headaches (r = 0.875, p<0.001). By the end of the experiment all patients had stopped medication. The data suggest strongly that intra-oral appliances constitute an effective non-invasive treatment option for Chronic Tension Type Headaches with disorders of pericranial muscles.

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Active Resistance Exercise for TMD Related Tension Pain.

R. SHATA, N.R. MEHTA, A.G. FORGIONE

(Tufts University School of Dental Medicine, Boston, MA USA).

 

Rocobado and Kraus have proposed exercises to relieve muscle tension pain related to TMD and craniocervical dysfunction. The Profile Toner^@  (Tasmark, Inc. N. Easton, MA) is an active resisted motion device originally designed for toning muscles of the neck to eliminated double chin. It is a polyurethane foam ball 5 inches in diameter. The purpose of this experiment was to examine the effect of active resisted motion exercise of the cervical flexors on pain reported in 10 body sites and neck mobility. Thirty female TMD patients (mean age 35.6 yr., range 24-48) were selected in order of appearance for treatment at a TMD center. They were assigned at random to either Experimental (E) or Control (C) groups of 15 each. For 8 weeks E subjects performed flexing exercises, bending the neck so as to compress the ball between the chin and chest (as a nut cracker) and a second set opening the mandible against the resistance of the ball. Finally the head was turned 45° and mandible pushed into the ball. C subjects performed the same number of exercises compressing the ball at the elbow joint.  Pain levels were recorded on 10, 10 point visual analogue scales pre and post experimentally. Rotation, bending and flexion were recorded on a protractor. The pain points of both groups pre-experimentally did not differ but the mean reduction of the E group (14.3, 43.7%) was significantly greater than that of the C group (2.6, 10%), t=3.9, p<0.001. TMJ pain reduction tended toward significance for the E group (p=0.058) as did headache (p=0.07) and face pain (p=0.08). Neck pain reduced significantly for the E group (mean=3.3 vs 0.5, t=4.6, df 29, p<0.001). A significant increase in right and left bending of the neck (7.0° vs 0.28° and 7.5° vs0.9°) as well as flexion (3.7° vs –2.6°) occurred in the E group. Neck exercises may be an effective adjunct to MPD treatment, reducing pain and increasing mobility of the neck. Supported by a grant from the Tasmark Inc.

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“Relationship between TMDs Pain, Somatization, Anxiety, Depression and SF-36 Scores."
J. ALGHAMDI, N. MEHTA, A. FORGIONE

(Tufts University School of Dental Medicine, Boston, MA USA).

 

519 Subjects were selected at random from a pool of 5000 patients attending a multidisciplinary facial pain center. Pain was measured by a pain score questionnaire composted of 20 Visual Analogue Scales (VAS). Ten pain sites were monitored, each by a VAS for the right and left sides. Possible scores were 0-10 for each VAS and 0-20 for each site with left and right scores being combined. A global pain score for each site was obtained by adding scores of all ten sites yielding a maximum possible score of 200. The purpose of the study was to determine the relationship between reported pain and three dimensions of the SCL-90 (somatization, anxiety and depression) and the global score of the SF-36. Although pain was significantly correlated (p<0.0001) with Somatization (r=0.52), Anxiety (r=0.31) and Depression (r=0.36), the coefficient of determination was relatively weak for each (r² =0.27, 0.10 and 0.11 respectively). Pain was not correlated with the SF-36 global score (r=0.015). On the other hand, Somatization scores were significantly correlated to Anxiety (r=0.66, r²=0.44), Depression (r=0.71, r²=0.50) and Anxiety significantly correlated with Depression (r=0.82, r²=0.67) with strong coefficients of determination. In order to ascertain whether high pain patients responded differently than low pain patients, patients were divided into two groups: total pain scores of <50 were placed in the Moderate pain group (mean 28.5) and total pain scores of $ 50 were placed in the Severe pain group (mean 83.9). In all three measures of the SCL-90, the Severe pain patients scores significantly higher than the Moderate pain patients (p<0.0001) but in all eight dimensions of the SF-36 there was no difference between Severe and Moderate pain responses. The scores of the three dimensions of the SCL-90, Somatization, Anxiety and Depression, suggested by Dworkin et al. are sensitive to differences in pain intensity while none of the dimensions of the SF-36 are. In addition, scores of the 3 SCL-90 scales are strongly intercorrelated.   

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The Effectiveness of Multi-faceted Treatment of TMDs: 519 patients drawn from a pool of 5,000.
(Presented at the Annual Meeting of the International Association of Dental Research, Chicago, 2001)

 J. ALGHAMDI, N. MEHTA, A. FORGIONE.

(Tufts University School of Dental Medicine, Boston, MA USA).

 

In this retrospective study, 519 subjects were selected at random from a pool of 5,000 patients who had completed treatment of attended at least three treatment sessions before terminating treatment. Treatment consisted of intraoral appliances: a soft upper for sleep and a mandibular repositioning device for daytime and a self administered home program for muscle relaxation. When indicated physical therapy was prescribed. Prior to treatment, on the next to last treatment and on the last treatment day, patients filled out a pain score sheet composed of 20 Visual Analogue Scales (VAS). Ten pain sites were monitored, each by a VAS for the right and left sides. Possible scores were 0-10 for each site and 0-20 for each site with left and right scores combined. A global pain score for each site was obtained by adding scores of all ten sites yielding a maximum possible score of 200. Pre-treatment mean pain was 54.6, next to last visit was 29.9 and last visit mean was 24.9. Each mean was significantly different p<0.001. An ANOVA was performed on the 10 pain site scores with significance level raised to 0.01. Pain in all sites decreased significantly from the pre-treatment baseline. Only subjects reporting pain in a site were studied. Each of the ten sites showed a significant reduction from a range of means 7.2-10 to 2.5-4.6. The post-treatment means of the five major diagnostic sites for TMDs (TMJ Pain, Clicking, Headache, Face Pain and Neck Pain) were compared to scores of 220 normal dental students as a control. The pain levels of the two groups were almost identical (means ranging from 3.8 to 4.2). Overall, 93% of patients showed improvement. An interesting finding of this research is that Neck, Upper Back and Lower Back pain decreased significantly with treatment of the oral condition. This lends support to the view that TMD treatment may affect areas outside the stomatognathic system. It was concluded that multidimensional treatment of TMDs is effective, reducing pain in 10 sites and in five sites to levels of dental student controls.