Fatores associados a presença de sinais e sintomas de disfunção temporomandibular em adolescentes

Orientador: Maria Beatriz Duarte GaviãoTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: Estudos epidemiológicos demonstram que sinais e sintomas de disfunção temporomandibular são comuns em adultos, constatando-se também, sua presença em crianças e adolescentes. O propósito deste estudo foi verificar a prevalência de sinais clínicos e sintomas de disfunção emporomandibular (DTM) em 217 adolescentes entre 12 e 18 anos, pertencentes a escolas da rede pública da cidade de Piracicaba e, também, as associações existentes com gênero (masculino e feminino), ansiedade, depressão e força de mordida. Os sinais clínicos foram avaliados através do Craniomandibular Index (CMI), o qual é composto de duas sub-escalas: Dysfunctional Index (DI) e Palpation Index (PI). Os sintomas subjetivos foram avaliados através de questionário. A escala Hospital Anxiety and Depression Scale (HADS) foi utilizada para avaliação dos níveis de ansiedade (HADSa) e depressão (HADSd). A força de mordida foi determinada em 40 voluntários, que apresentavam valores extremos (mínimo e máximo) para o CMI, os quais foram distribuídos em dois grupos: Grupo I ¿ 20 adolescentes sem DTM (valores extremos mínimos do CMI e ausência de sintoma) e Grupo II ¿ 20 adolescentes com DTM (valores extremos máximos do CMI e presença de pelo menos 1 sintoma). Para a obtenção da força de mordida foi utilizado um tubo pressurizado de fibra reforçada, conectado a um sensor de pressão. Os resultados para os sinais clínicos mostraram que (1) para sensibilidade à palpação dos músculos da cabeça e pescoço ocorreu grande variação na amostra total (0,9%-32,25%); (2) 10,6%, 10,6% e 7,83% dos adolescentes apresentaram sensibilidade à palpação nas regiões superior, dorsal e lateral da articulação temporomandibular, respectivamente; (3) 19,8% e 14,7% da amostra apresentaram ruído articular durante a abertura e fechamento bucal, respectivamente. Ruído articular (26,72%) e dor de cabeça (21,65%) foram os sintomas subjetivos mais prevalentes nos adolescentes. Não foram encontradas diferenças entre os gêneros na prevalência de sinais e sintomas de DTM, exceção feita à sensibilidade à palpação do pterigóideo lateral. As correlações entre os valores dos índices (DI, PI, CMI) e HADSa e HADSd foram estatisticamente significativas apenas entre CMI, PI e HADSa (p<0,01). O número de sintomas subjetivos associou-se significativamente tanto com HADSa quanto para o HADSd (p<0,01). A força de mordida foi estatisticamente maior no grupo I (325,90 N) do que no grupo II (301,51 N), sendo que as meninas deste grupo apresentaram valores significativamente menores. Ocorreu correlação negativa significativa entre CMI e PI e a magnitude da força de mordida (p<0,01). Não houve correlações significativas nas variáveis corporais e etárias com a força de mordida. Concluiu-se que os sinais e sintomas de DTM, presentes em indivíduos jovens, podem ser influenciados pela ansiedade e depressão, bem como comprometer as funções do sistema estomatognático, como se comprovou com a redução da força de mordida, principalmente no gênero femininoAbstract: Epidemiologic studies have demonstrated that signs and symptoms of temporomandibular dysfunction (TMD) are common in adults, evidencing also its presence in children and adolescents. The aim of this study was to verify the prevalence of clinical signs and subjective symptoms of TMD in 217 adolescents aged from 12 to 18 years old from public schools in the city of Piracicaba and the associations with gender, anxiety, depression and bite force magnitude. The clinical signs were evaluated using the Craniomandibular Index (CMI), which is divided into two sub-scales: Dysfunction Index (DI) and Palpation Index (PI). The subjective symptoms were evaluated through a questionnaire. The levels of anxiety (HADSa) and depression (HADSd) were verified using the Hospital Anxiety and Depression Scale (HADS). Bite force was determined in 40 volunteers with lower and upper extremity values of CMI who were distributed in two groups: Group I ¿ 20 adolescents without TMD (lower extremes values of CMI and absence of subjective symptoms) and Group II ¿20 adolescents with TMD (upper extremes values of CMI and at least one subjective symptom) Bite force was obtained with a transducer, which consisted of a pressurized rubber tube connected to a sensor element. The results for clinical signs showed that (1) tenderness in head and neck muscles, demonstrated a great variability (0.9%-32.25%); (2) temporomandibular joint tenderness, in the superior, dorsal and lateral condyle regions, occurred in 10.6%, 10.6% and 7.83% respectively, (3) the percentage of joint sounds in mouth opening and closing was 19.8% and 14.7% respectively. Joint sounds (26.72%) and headache (21.65%) were the most prevalent symptoms in the total sample. Gender differences were not found in the prevalence of TMD signs and symptoms, except for the lateral pterygoid muscle tenderness. The correlations between indexes values (DI, PI, CMI) and HADSa and HADSd were statistically significant only with CMI, PI and HADSa (p<0.01). The number of subjective symptoms showed a significant association with HADSa and HADSd (p<0.01). Bite force was statistically higher in group I (325.90 N) than in group II (301.51 N). Girls in Group II had the smallest bite force values (p<0.05). There was a significant negative correlation between CMI and PI and bite force magnitude. There were not significant correlations between bite force and body variables and age. It was concluded that clinical signs and symptoms of TMD present in adolescents, can be influenced by anxiety and depression, decreasing the stomathognatic system functions as demonstrated by bite force reduction, primarily in girlsDoutoradoFisiologia OralDoutor em Odontologi

Efeito do tramadol e dipirona nas respostas comportamentais nociceptivas induzidas pela administração de oleo de mostarda na ATM de ratos

Orientador : Maria Cecilia Ferraz de Arruda VeigaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: Embora sejam uma importante entidade clínica, as desordens da Articulação Temporomandibular (ATM), representam um problema de difícil tratamento, e principalmente, causam enorme desconforto e geralmente inflamação seguida de dor. Portanto, o desenvolvimento e a padronização de modelos experimentais que possibilitem o estudo dos mecanismos fisiológicos envolvidos nesse tipo específico de condições dolorosas são de grande relevância. Para isso, 50 jlL de óleo de mostarda (OM) (1,5%,2,5% e 4,5%) ou seu veículo óleo mineral foram administrados na região da ATM direita de ratos e as respostas comporta mentais nociceptivas caracterizadas pelo ato de coçar a região orofacial (CO) e levantar rapidamente a cabeça (LC) foram quantificadas por 45 minutos. A administração periarticular de OM produziu respostas comportamentais nociceptivas estatisticamente significativas a partir da concentração de 2,5% em relação à de óleo mineral. Com o intuito de confirmar o caráter nociceptivo das respostas comportamentais induzidas pela administração de OM na A TM, foram realizados grupos experimentais adicionais, nos quais o QX-314 (quaternário hidrofílico derivado da lidocaína) - 2% ( 25µL) foi co-administrado com o OM (5% -25µL) e a morfina foi administrada via intraperitoneal (i.p.) 30 minutos antes da administração do OM (2,5% - 50µL) na região da ATM. A seguir para se verificar o efeito de drogas analgésicas nessas respostas nociceptivas foram adiministradas, via i.p., dipirona (19; 57; 95mg/kg) e tramadol (5; 7,5; 10mg/kg) 30 minutos antes da administração de OM 2,5%. Os resultados indicam que o OM quando injetado diretamente na A TM de ratos é capaz de desencadear respostas comportamentais nociceptivas que são significativamente reduzidas pela co-administração de QX-314 - 2% e pela administração Lp. de morfina, e que este modelo comportamental é sensível aos analgésicos tramadol e dipirona, os quais reduziram de maneira dose dependente as respostas comportamentais nociceptivas avaliadas nesta pesquisaAbstract: Although they are an important clinical entity, Temporomandibular disorder (TMD), causing a lot of discomfort and usually inflammation followed by pain, requires very complex reatment. Therefore, the development and the standardization of experimental models that make the study of physiologic pain mechanisms possible are of great relevance. For this, 50 j.JL of 1.5%, 2.5% and 4.5% mustard oil (MO), as well as its vehicle, the mineral oil, was administered in the right temporomandibular joint (TMJ) of rats. Nociceptive behavioral responses characterized by the rat's both rubbing the orofacial region and flinching their heads quickly were quantified for 45 minutes. When compared to mineral oil administered in the periarticular region, MO showed nociceptive behavioral responses (statistically significant) starting at a concentration of 2.5%. With the intention of confirming the nociceptive character of the behavioral responses induced by the administration of MO in TMJ, two experimental groups were tested: group 1 - 25j.JL of QX 314 at 2% (derived from the lidocaine) CQ-administered with 5% MO (25j.JL); group 2 ¿ morphine was intraperitoneally (i.p.) administered 30 minutes before the administration of 2.5% MO (50j.JL). In order to verify the effect of analgesic drugs on behavioral responses, dipyrone (19; 57; 95mg/kg) and tramadol (5; 7.5; 10mg/kg) were administered (i.p.) 30 minutes before the administration of 2,5% MO. Results in the present study show that when rats were injected with MO directly into the TMJ, nociceptive behavioral responses could be observed and these responses were significantly reduced by the co-administration of QX-314 at 2% and by the 5 administration of morphine. Also, this behavioral model was sensitive to the analgesic tramadol and dipyrone, which reduced the nociceptive behavioral responses in dependent dose appraised in this researchMestradoFisiologia OralMestre em Odontologi

Movimentos mandibulares em crianças portadoras ou não de sinais e sintomas de disfunção temporomandibular

This research aimed to evaluate mandibular movements in children with and without signs and symptoms of temporomandibular dysfunction. The sample taken consisted of 99 children aged 3 to 5 years distributed in two groups: I - Absence of signs and/or symptoms of TMD (25 girls/40 boys); II - Presence of signs and symptoms of TMD (16 girls/18 boys). The symptoms were evaluated through an anamnesis questionnaire answered by the child's parents/caretakers. The clinical signs were evaluated through intra- and extraoral examination. Maximum mouth opening and left/right lateral movements were measured using a digital caliper. The maximum protrusive movement was measured using a millimeter ruler. The means and standard deviations for maximum mouth opening in Group I and Group II were 40.82mm±4.18 and 40.46mm±6.66, respectively. The values found for the left lateral movement were 6.96mm±1.66 for Group I and 6.74mm±1.55 for Group II, while for the right lateral movement they were 6.46mm±1.53 and 6.74mm±1.77. The maximum protrusion movements were 5.67mm±1.76 and 6.12mm±1.92, in Groups I and II, respectively. The mandibular movement ranges neither differed statistically between groups nor between genders. FAPESP Process 96/0714-6.O objetivo desta pesquisa foi avaliar a amplitude dos movimentos mandibulares em crianças portadoras ou não de sinais e sintomas de disfunção temporomandibular. A amostra consistiu de 99 crianças entre 3 e 5 anos distribuídas em 2 grupos: I - Ausência de sinais e sintomas de DTM (25 meninas/40 meninos) II - Presença de sinais e sintomas de DTM (16 meninas/18 meninos). Os sintomas foram avaliados através de um questionário respondido pelos pais ou responsáveis das crianças. Os sinais clínicos foram avaliados através de exame intra e extra-oral por dois examinadores calibrados. Os movimentos de abertura máxima e lateralidade direita e esquerda foram mensurados com o auxílio de um paquímetro digital. Para o movimento de protrusão foi utilizada régua milimetrada. A média e o desvio padrão para abertura bucal máxima para o grupo I foi de 40,82mm±4,18 e para o grupo II 40,46mm±6,66. Os valores encontrados para a lateralidade esquerda foram 6,96mm±1,66 para o grupo I e 6,74mm±1,55 para o grupo II e, para a direita, foram 6,46mm±1,53 e de 6,74mm±1,77, respectivamente. Durante a protrusão foram encontrados valores de 5,67mm±1,76 para o grupo I e 6,12mm±1,92 para grupo II. Pode-se concluir que na amostra avaliada a amplitude dos movimentos mandibulares não diferiu estatisticamente entre os grupos, bem como entre os gêneros. FAPESP Processo 96/0714-6

Effects of acute mental stress on conditioned pain modulation in temporomandibular disorders patients and healthy individuals

Stress is a contributing factor to painful temporomandibular disorders (TMD). Nevertheless, the underpinnings of this relationship are not fully understood.&nbsp;Objective: To investigate the effects of acute mental stress on conditioned pain modulation (CPM) in TMD patients compared with healthy individuals.&nbsp;Methodology: Twenty women with chronic myofascial TMD diagnosed according to the RDC/TMD and 20 age-matched healthy women had the CPM assessed before and after a stressful task using the Paced Auditory Serial Addition Task (PASAT) in a single session. Subjective stress response was assessed with the aid of visual analog scale (VAS). Pressure pain threshold (PPT) on masseter muscle was the test stimulus (TS) and immersion of the participant’s hand on hot water was the conditioning stimulus (CS) - CPM-sequential paradigm.&nbsp;Results: Healthy individuals reported PASAT are more stressful when compared with TMD patients and the stress task did not affect the CPM in neither group. Nonetheless, a negative correlation was observed between change in CPM and change in TS from baseline to post-stress session, which indicates that the greater the increase in PPT after the stress task, the greater was the decrease in CPM magnitude. The correlation was strong for healthy controls (r=- 0.72, p&lt;0.001) and moderate for TMD patients (r=- 0.44, p=0.047).&nbsp;Conclusions: The correlation between the change in CPM and the TS change following the stress task may possibly indicate an overlapping pathway between stress-induced analgesia/hyperalgesia and descending pain inhibition

Can palpation-induced muscle pain pattern contribute to the differential diagnosis among temporomandibular disorders, primary headaches phenotypes and possible bruxism?

Background: The evaluation of possible differences in the distribution or characteristics of palpation-induced pain in the masticatory muscles could be valuable in terms of diagnostic assessment. The aim of this study was to evaluate the impact of different combinations of anterior temporalis (AT) and masseter palpation-induced pain in the diagnostic of temporomandibular disorder (TMD), primary headaches and bruxism. Material and Methods: A total of 1200 dental records of orofacial pain adult patients were analyzed. The outcomes were dichotomously classified (presence/absence) as following: a) AT and/or masseter palpation-induced pain; b) myogenous TMD; c) temporomandibular joint (TMJ) arthralgia (arthrogenous TMD); d) migraine; e) tension-type headache (TTH); f) self-reported bruxism. Binomial logistic regression model (α = 5%) was applied to the data considering the palpation-induced muscle pain as the dependent variable. Results: Mean age (SD) were 35.7 years (13.4) for 635 included dental records (83% females). Myogenous and arthrogenous TMD, migraine, TTH and bruxism were mainly associated with, respectively, masseter palpationinduced pain (p<0.001 - OR=5.77, 95%CI 3.86-8.62), AT or masseter palpation-induced pain (p<0.001 - OR=2.39, 95%CI 1.57-3.63), bilateral AT palpation-induced pain (p<0.001 - OR=2.67, 95%CI 1.64-4.32), masseter and AT palpation-induced pain (p=0.009 - OR=1.62, 95%CI 1.12-2.33) and bilateral masseter palpation-induced pain (p=0.01 - OR=1.74, 95%CI 1.13-2.69). Conclusions: Palpation-induced pain in the masticatory muscles may play a role in the differential diagnosis among painful TMD, primary headaches and bruxis

Primary headaches interfere with the efficacy of temporomandibular disorders management

OBJECTIVES: This cross-sectional study aimed to evaluate the influence of Primary Headache (PH) on efficacy of a Temporomandibular Disorders (TMD) conservative therapy and its association with the presence of self-reported parafunctional habits. SAMPLE AND METHODS: Sample was composed of 400 medical records, divided into four groups: I) Muscular TMD (n=64); II) Muscular TMD+PH (n=48); III) Muscular TMD+Articular TMD (n=173); IV) Muscular TMD+Articular TMD+PH (n=115). All groups had undergone a TMD therapy for three months with a stabilization appliance and counseling for habits and behavioral changes, with no specific headache management. Current pain intensity and existence or not of self-reported bruxism were assessed. Repeated measures ANOVA and Chi-Square test followed by Odds were used for statistical analysis, with a significance level of 5%. RESULTS: results of this study showed that: (1) A conservative therapy with stabilization appliance and counseling for habits and behavioral changes was effective in the TMD pain relief; (2) Groups with an additional diagnosis of PH had worsened the pain improvement significantly; and (3) no association between the presence of self-reported bruxism and PH was found. CONCLUSIONS: this study could elucidate the important effect that headache may have on the TMD management

Deep pain sensitivity is correlated with oral-health-related quality of life but not with prosthetic factors in complete denture wearers

Low pressure Pain Threshold (PPT) is considered a risk factor for Temporomandibular Disorders (TMD) and is influenced by psychological variables. Objectives To correlate deep pain sensitivity of masticatory muscles with prosthetic factors and Oral-Health-Related Quality of Life (OHRQoL) in completely edentulous subjects. Material and Methods A total of 29 complete denture wearers were recruited. The variables were: a) Pressure Pain Threshold (PPT) of the masseter and temporalis; b) retention, stability, and tooth wear of dentures; c) Vertical Dimension of Occlusion (VDO); d) Oral Health Impact Profile (OHIP) adapted to orofacial pain. The Kolmogorov-Smirnov test, the Pearson Product-Moment correlation coefficient, the Spearman Rank correlation coefficient, the Point-Biserial correlation coefficient, and the Bonferroni correction (α=1%) were applied to the data. Results The mean age (standard deviation) of the participants was of 70.1 years (9.5) and 82% of them were females. There were no significant correlations with prosthetic factors, but significant negative correlations were found between the OHIP and the PPT of the anterior temporalis (r=-0.50, 95% CI-0.73 to 0.17, p=0.005). Discussion The deep pain sensitivity of masticatory muscles in complete dentures wearers is associated with OHRQoL, but not with prosthetic factors

Ultrasonographic evaluation of masticatory muscles and facial dimensions in children with unilateral posterior crossbite

PURPOSE: to evaluate the ultrasonographic thickness of masseter and anterior portion of the temporalis muscle and facial dimensions in children with normal occlusion and unilateral crossbite, in deciduous and early mixed dentition. METHODS: the sample comprised 49 children of both genders, divided into four groups: deciduous-normal occlusion, deciduous-crossbite, mixed_normal occlusion and mixed_crossbite. Muscle thickness was compared between the right and left sides (normal occlusion) and normal and crossbite-side (crossbite) (Student's t test) and related to facial dimensions and body variables (Pearson's and Spearman's correlation test). Facial dimensions were determined by measuring standardized frontal photographs: anterior facial height (AFH), bizygomatic (FWB) and intergonial width (FWI), and AFH/FWB and AFH/FWI ratios. RESULTS: the results showed that the anterior temporalis muscle at rest was significantly thicker in the crossbite side in the mixed-crossbite group (p=0.05). Masseter thickness did not show significant differences between the sides in all groups. Weight and height did not correlate with masticatory muscle thickness; but FWB and FWI showed being positive, and AFH/FWB and AFH/FWI ratios showed having negative correlation with masseter thickness, i.e. children with a long-face pattern showed smaller muscle thickness. CONCLUSION: in the sample studied, the influence of functional characteristics on craniofacial structures was observed in young children by masticatory muscles ultrasonography and facial dimensions exam.OBJETIVO: avaliar a espessura dos músculos masseter e porção anterior do temporal por meio da ultra-sonografia e as dimensões faciais de crianças com oclusão normal e mordida cruzada posterior unilateral, na dentição decídua e mista inicial. MÉTODOS: foram selecionadas 49 crianças, de ambos os gêneros, divididas em quatro grupos: decídua-oclusão normal, decídua-mordida cruzada, mista-oclusão normal e mista-mordida cruzada. A espessura muscular foi comparada entre os lados direito e esquerdo (oclusão normal); e normal e cruzado (mordida cruzada) (teste t Student), e relacionada às dimensões faciais e variáveis corporais (teste de correlação de Pearson e Spearman). As dimensões faciais foram mensuradas sobre fotografias frontais padronizadas: altura facial anterior (AFA), distância bizigomática (DB) e intergoniana (DI) e razões AFA/DB e AFA/DI. RESULTADOS: observou-se que o músculo temporal no repouso apresentou espessura maior no lado cruzado no grupo mista-cruzada (p=0,05). O masseter não apresentou diferença significativa entre os lados em todos os grupos. As variáveis peso e altura não apresentaram correlação com a espessura muscular; já DB e DI apresentaram correlação positiva e as razões AFA/DB e AFA/DI, correlação negativa, com a espessura do masseter em todos os grupos, indicando que crianças com faces mais longas possuem menor espessura deste músculo. CONCLUSÃO: na amostra estudada, os exames da espessura dos músculos mastigatórios e das dimensões faciais demonstraram que a influência das características funcionais sobre as estruturas craniofaciais pôde ser observada já em crianças de pouca idade.617

A rentabilidade das indústrias nacionais de cortiça: na ótica da gestão de tesouraria.

Dissertação de Mestrado Apresentado ao Instituto de Contabilidade e Administração do Porto para a obtenção do grau de Mestre em Contabilidade e Finanças, sob orientação de Mestre Adalmiro Álvaro Malheiro de Castro Andrade Pereira.A atual conjuntura económica tem vindo a exigir às empresas uma incessante eficiência quanto à gestão do fundo maneio. Assim, a gestão do fundo maneio constitui uma das funções mais importantes dentro de uma empresa, que visa financiar o ciclo de exploração da empresa sem comprometer o seu funcionamento normal e a sua atividade. Neste âmbito importa distinguir as indústrias das restantes empresas. As indústrias apresentam um prazo médio de existências bastante elevado, originando um montante elevado de ativos correntes. Porém, em contrapartida apresentam prazos médios de recebimento e pagamento mais curtos, que exigem das entidades organizacionais um esforço contínuo na gestão de liquidez que permita honrar os seus compromissos a curto prazo e com a maior rentabilidade possível. O objetivo deste estudo é analisar o impacto da gestão do fundo maneio na rentabilidade operacional das empresas, utilizando para o efeito uma amostra das indústrias do sector da cortiça em Portugal. Os dados obtidos reportam um painel de 987 observações respeitantes a 329 empresas para o período de tempo 2010-2012, isto é, são dados com periodicidade anual. Para tal para além de uma análise descritiva dos dados é estimado um modelo econométrico utilizando o método de efeitos fixos para estimação em dados em painel. Os resultados apontam que o cash conversion cycle (em dias) afeta de forma significativa a rentabilidade operacional da empresa. Os gestores poderão aumentar a rentabilidade da empresa através da redução do net trade cycle, do prazo médio de existências e do prazo médio de recebimentos. Ao contrário do prazo médio de recebimentos, a empresa deveria conseguir negociar com os seus fornecedores para alargar o prazo médio de pagamentos. Por outro lado, o crescimento das vendas juntamente com o grau de alavancagem operacional, apresentam um efeito positivo significativo sobre a rentabilidade operacional da empresa como um todo. Por último, relativamente ao nível de endividamento da empresa para assegurar a sua atividade normal, quanto menor o nível de endividamento maior a rentabilidade da entidade organizacional.The current economic environment has demanded that companies are run with relentless efficiency when managing their working capital. The management of working capital is one of the most important activities within a company, which aims to finance the operating cycle without compromising their normal activity. In industries it is known that the average inventory period is quite low, which justifies higher current assets. However, the average collection and payment periods are shorter, which requires an organisation ongoing effort managing the liquidity, to honour their commitments in the short term and maximize their profitability. The aim of this study is to analyse the impact of the working capital management within the profitability of a company using, as a case study, the Portuguese cork industry. The data includes 987 companies for the period between 2010 and 2012, using a fixed effect econometric model to estimate the hypothesis. The results shows that the cash conversion cycle significantly affects the company's profitability. Managers may increase this profitability by reducing net trade cycle, the average inventory period and average collection periods. Unlike the average collection period, the companies should also be able to negotiate with their suppliers to extend average payment periods. On the other hand, sales growth along with an increased operational leverage have a significant positive effect on the profitability of the companies. Finally, for the level of debt needed to ensure the normal activity of a company, we can conclude that, the lower the level of debt the greater the profitability. An efficient management of working capital implies an ongoing effort to guarantee the appropriate level of current financial assets and liabilities, leading to the increase of the profitability of companies