Bilateral asymptomatic fibrous-ankylosis of the temporomandibular joint associated with rheumatoid arthritis: a case report

The American Academy of Orofacial Pain (AAOP) defines ankylosis of the temporomandibular joint (TMJ) as a restriction of movements due to intracapsular fibrous adhesions, fibrous changes in capsular ligaments (fibrous-ankylosis) and osseous mass formation resulting in the fusion of the articular components (osseous-ankylosis). The clinical features of the fibrous-ankylosis are severely limited mouth-opening capacity (limited range of motion during the opening), usually no pain and no joint sounds, marked deflection to the affected side and marked limitation of movement to the contralateral side. A variety of factors may cause TMJ ankylosis, such as trauma, local and systemic inflammatory conditions, neoplasms and TMJ infection. Rheumatoid arthritis (RA) is one of the systemic inflammatory conditions that affect the TMJ and can cause ankylosis. The aim of this study is to present a case of a female patient diagnosed with bilateral asymptomatic fibrous-ankylosis of the TMJ associated with asymptomatic rheumatoid arthritis. This case illustrates the importance of a comprehensive clinical examination and correct diagnosis of an unusual condition causing severe mouth opening limitation

Determination of the proper Pressure Pain Threshold (PPT) for the diagnosis of Temporomandibular Joint (TMJ) arthralgia: a magnetic ressonance and algometer - based study

A Articulação Temporomandibular (ATM) pode ser acometida por inúmeros distúrbios articulares sendo os mais comuns os distúrbios de desarranjo do disco e os distúrbios inflamatórios. Um sinal clínico importante nesses casos é a sensibilidade dolorosa à palpação digital ou por mensuração do Limiar de Dor à Pressão (LDP), determinado com o uso de um instrumento denominado algômetro. O presente trabalho tem o objetivo de determinar qual o valor de LDP que melhor diferencie ATMs saudáveis daquelas acometidas por distúrbios inflamatórios e dolorosos. Ainda propõem-se a determinar se há diferenças entre o LDP de ATMs saudáveis e ATMs com deslocamento de disco com redução (DDCR) assintomáticos. Para isso, foi utilizada uma amostra de 60 indivíduos de ambos os gêneros com idade entre 18 e 50 anos, avaliados pelos critérios do Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) e divididos em três grupos: 20 indivíduos com diagnóstico clínico de artralgia da ATM (com ou sem deslocamento de disco para anterior, 20 indivíduos com diagnóstico clínico de DDCR (assintomáticos) e 20 indivíduos sem dores ou ruídos na ATM (grupo controle). Toda a amostra foi submetida a exame de ressonância magnética para análise da posição do disco para confirmar o exame físico e validar os critérios de inclusão (RDC/TMD) para formação dos grupos. Foram realizados exames de algometria sobre o pólo lateral das ATMs, e obtidas Escalas de Análise Visual (EAV) para o grupo de artralgia. Os dados foram analisados por teste de análise de variância (ANOVA a um critério) e por teste de correlação de Pearson com 5% de significância. Níveis de especificidade e sensibilidade, sendo gerada curva ROC foram também determinados. O valores de LDP foram significantemente menores para o grupo com artralgia (média de 1,07 kgf/cm2 ± 0,445), quando comparados aos outros grupos. Ainda, o grupo com DDCR (média de 1,90 kgf/cm2 ± 0,647) apresentou menores valores quando comparados ao controle (média de 2,46 kgf/cm2 ± 0,593). Não foi encontrada correlação entre o LDP obtido no grupo de artralgia com a EAV e com o tempo de experiência de dor. Quando excelentes valores de sensibilidade e especificidade foram contemplados, verificou-se que o valor de palpação de 1,56 kgf/cm2 é o mais adequado para o diagnóstico de DTM de origem articular.Temporomandibular Joint (TMJ) internal derangements are characterized by anterior disk displacement (ADD) and/or as arthralgias. An important clinical presentation in these cases is the painful tenderness to manual palpation or decreased Pressure Pain Threshold (PPT), determined with an algometer. The present study aims to determine, based on high specificity levels, the more appropriate PPT value to discriminate healthy TMJs from those with painful inflammatory processes as well as to determine the influence of asymptomatic disk displacement with reduction (DDWR) in this scenario. A sample of 60 individuals from both genders with age between 18 and 50 years were evaluated by Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and divided into three groups: 20 patients with clinical diagnosis of TMJ arthralgia, 20 patients with clinical diagnosis of asymptomatic DDWR and 20 individuals with no TMJ pain or noise (control group). All individuals were submitted to an exam of magnetic resonance imaging for the analysis of disk position to confirm the physical exam (RDC/TMD) and to validate the group distribution. An algometry exam was performed on the TMJ lateral pole and the individuals of the arthralgia group also filled out a Visual Analogue Scale (VAS). The data were analyzed by variance test (ANOVA) and by Pearson correlation test with 5% of significance. Levels of specificity and sensibility, and ROC curves were also determined. The arthralgia group presented significant lower PPT (mean of 1.07 kgf/cm2 ± 0.445) values than the others. DDWR group (mean of 1.90 kgf/cm2 ± 0.647) has shown significant lower PPT values when compared to the control group (mean of 2.46 kgf/cm2 ± 0.593). A significant correlation between the PPT and the VAS and the time of pain experience was not found. 100% of specificity and 90% of sensitivity were obtained when 1.56 kgf/cm2 was applied to the TMJ (ROC=0.99). This value was considered to be the most appropriate to detected TMJ arthralgia

Efeito de antagonistas de receptores opióides específico e não-específicos na Hipoalgesia-Induzida por Exercício (HIE)

The opioid system is involved in a well-documented biological phenomenon named Exercise-induced Hypoalgesia (EIH) but the exact mechanism(s) are not clear. Studies demonstrate that exercise effects could be reversed by naloxone but there are no studies that evaluate the role of specific opioid receptors in the EIH levels. The present study aimed to evaluate the role of a non-specific (naltrexone) and specific opioids receptors (mu, kappa and delta) antagonists on the EIH levels induced by aerobic exercise in the Rota-Rod in a hundred and eighty (n=180) healthy male adult Sprague-Dawley rats. Rats were divided into five groups (naltrexone, vehicle, mu, kappa, delta) and each group was subdivided into high (67% EIH 100%), medium (34% EIH 66%) or low (EIH 33%) EIH profile level. After 3 days of habituation, EIH baseline measurements (percentage of response to 30 mechanical stimuli with 60g Von Frey monofilaments) at 1, 5, 10 and 20 minutes following exercise were assessed. In the day after the baseline measurements, thirty rats from each group (10 high, 10 medium and 10 low EIH) rats were injected with naltrexone hydrochloride, CTAP (mu receptor antagonist), GNTI (kappa receptor antagonist), Naltrindole hydrochloride (delta receptor antagonist), or vehicle (distilled water solution). Then, after 10 minutes (for naltrexone and vehicle), 20 minutes (for mu), 15 minutes (for kappa) and 10 minutes (for delta), EIH measurements were obtained again, just once. Data were analyzed with repeatedmeasurements ANOVA, followed by post-hoc Fisher test. Alpha was set at 0.05. Injection with the vehicle (distilled water) did not reduce the EIH (p=0.904), differently, naltrexone hydrochloride (p=0.000), kappa (p=0.002) and delta (p=0.000) antagonists drugs significantly reduced the EIH 1 minute following exercise when compared to baseline. It was concluded that rats with high EIH profile had a significant EIH reduction after injection of a non-specific and some specific opioid receptors antagonist (delta and kappa). The EIH effect, however, was just partially reduced, suggesting that others mechanism are involved in EIH phenomenon. The findings reveal that exercise induces hypoalgesia in healthy rats. More studies are needed to evaluate the phenomenon and the mechanisms of EIH in humans with painful disorders such as chronic musculoskeletal pain and orofacial painO sistema opióide está envolvido em um fenômeno biológico bem documentado na literatura chamado Hipoalgesia-induzida por Exercício (HIE), mas o exato mecanismo ainda não é claro na literatura. Estudos demonstram que os efeitos do exercício podem ser revertidos por substâncias antagonistas não-específicas dos receptores opióides, mas não existem estudos que avaliem o papel específico dessas substâncias na HIE. O presente estudo objetivou avaliar o papel de antagonistas não-específico e específicos de receptores opióides nos níveis de HIE com exercício aeróbico em cento e oitenta (180) ratos (Sprague-Dawley) machos adultos e saudáveis. Os ratos foram divididos em cinco grupos (naltrexona, veículo, mu, kappa, delta) e cada grupo, subdividido em alto (67% HIE 100%), médio (34% HIE 66%) ou baixo (HIE 33%) nível de HIE. Após 3 dias de habituação, medidas de HIE (porcentagem de resposta a 30 estímulos mecânicos realizados com o monofilamento de von Frey de 60g) em 1, 5, 10 e 20 minutos após o exercício foram realizadas. No dia seguinte, trinta ratos de cada grupo (10 de cada perfil de HIE) foram injetados com naltrexona, CTAP (antagonista do receptor mu), GNTI (antagonista do receptor kappa), cloridrato de naltrindole (antagonista do receptor delta), ou veículo (solução de água destilada) e, em seguida, depois de 10 minutos (para a naltrexona e veículo), 20 minutos (para mu), 15 minutos (para kappa) e 10 minutos (para delta), as medições de HIE foram novamente realizadas (apenas uma vez). Dados foram analisados com ANOVA seguido pelo teste post-hoc Fisher. Valor geral de alfa foi de 0,05. Injeção com o veículo (água destilada) não reduziu a HIE (p = 0,904). Diferentemente, naltrexona (p=0,000), kappa (p=0,002) e delta (p=0,000) antagonistas reduziram significativamente a HIE no primeiro minuto seguinte ao exercício quando comparados com o valor basal. Concluiu-se que os ratos com alto nível de HIE tiveram uma redução significativa do HIE após a injeção de naltrexona e antagonistas dos receptores delta e kappa, mas o efeito HIE foi parcialmente reduzido, sugerindo que outros mecanismos estão envolvidos na HIE. Os achados revelam que o exercício induz hipoalgesia em ratos saudáveis. Mais estudos são necessários para avaliar o fenômeno e os mecanismos da HIE em seres humanos com desordens dolorosas como dor crônica musculoesquelética e dor orofacial

Orofacial pain and temporomandibular disorders: the impact on oral health and quality of life

Many conditions may cause painful symptoms in orofacial structures. Among the chronic conditions that affect this area, temporomandibular disorders are the most common. Temporomandibular Disorder is a collective term that includes a number of clinical complaints involving the masticatory muscles, the Temporomandibular Joint and associated structures. In some cases, these complaints can be associated with depression, catastrophizing behavior and impact on quality of life. The present study aims to explain the relationship between Temporomandibular Disorders and pain chronification and their relation to a variety of psychosocial and behavioral comorbid conditions. The mechanisms of pain conduction and suggestions for management are also addressed

Influence of myofascial pain on the pressure pain threshold of masticatory muscles in women with migraine

Objective: To evaluate the influence of myofascial pain on the Pressure Pain Threshold (PPT) of masticatory muscles in women with migraine. Methods: The sample comprised 101 women, ages ranging from 18 to 60 years, with an episodic migraine diagnosis previously confirmed by a neurologist. All patients were evaluated using Research Diagnostic Criteria for Temporomandibular Disorders to determine the presence of myofascial pain and were divided into 2 groups: group I (n=56), comprising women with a migraine, and group II (n=45), comprising women with a migraine and myofascial pain. Two more groups (49 asymptomatic women and 50 women with myofascial pain), matched for sex and race, obtained from a previous study, were added to this study. The PPT values of masseter and temporalis (anterior, middle, and posterior regions) muscles were recorded bilaterally using a pressure algometer. One-way analysis of variance and the Tukey test for pairwise comparisons were used in statistical analysis with a 5% significance level. Results: We found that all groups had significantly lower PPT values compared with asymptomatic women, with lower values seen in group II (women with migraine and myofascial pain). Women with a migraine and myofascial pain showed significantly lower PPT values compared with women with a migraine only, and also when compared with women with myofascial pain only. Discussion: Migraine, especially when accompanied by myofascial pain, reduces the PPT of masticatory muscles, suggesting the importance of masticatory muscle palpation during examination of patients with migraine