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Prevalence and association of headaches, temporomandibular joint disorders, and occlusal interferences

Headache is a widespread ail- tion and modulation via interneuro- cluded data such as gender, age, edu- Prevalence and association of ment. Both temporomandibular joint nal input may eventually trigger an cation, and socioeconomic status as headaches, temporomandibular joint disorders (TMD) and headache have overlap of spinal innervation from the influence of demographic factors major impacts on the quality of life.1 muscular proprioceptive areas to pain on the etiology of TMD and headache disorders, and occlusal interferences Studies report a lifetime prevalence of areas.38,40-43 is scientifically controversial.2,48-51 every headache type for 69% of men As stated, clinical practice experi- Consumption of substances such as and 88% of women.2-9 Lupoli and ence suggests that headache and den- alcohol, caffeine, and nicotine, and M. Troeltzsch, DMD, MD,a M. Troeltzsch, DMD,b R.J. Cronin,
Lockey10 report that 10 million Ameri- tal pathology are intertwined. Never- the presence of psychological factors DDS, MS,c A.H. Brodine, DMD,d R. Frankenberger, DMD, PhD,e
cans cope with frequent headaches. theless, only a few studies44-46 indicate including fear of the future, depres-Although the etiological factors of such a correlation. The purpose of sion, psychiatric therapy, or use of an- and K. Messlinger, MD, PhDf
headaches are not fully understood, this study was to identify the presence tipsychotic drugs were also analyzed Friedrich Alexander University Erlangen-Nuremberg, Erlangen, vascular/neurologic factors, age, gen- or absence of an association of occlu- as the literature indicates that there Germany; University of Texas Health Science Center at San der, and muscular hypertension of sal interferences, parafunction, TMD, may be an influence.52the masticatory and cervical muscles or physiologic, muscular, or prosth- Each patient's medical history was Antonio, San Antonio, Texas; University of Rochester, Eastman are reported.2,11 Furthermore, dis- odontic factors with the occurrence queried for cardiovascular disease, Institute for Oral Health, Rochester, NY; Phillips-University orders in the temporomandibular of headache.
hypertension, diabetes, orthopedic joint region have been suspected and problems, and lung, kidney, and liver Marburg, Germany, Ansbach, Germany.
shown to influence the etiology, fre- MATERIAL AND METHODS disease because these were consid- quency, intensity, and chronicity of ered relevant after thorough literature Statement of problem. Although an interaction of malocclusion, parafunction, and temporomandibular joint disor-
headache.10,12-22 In fact, the correla- This cross-sectional study was review.2 The prevalence of habits such ders (TMD) can be inferred from the experience of daily practice, scientific evidence to corroborate this hypothesis tion for headache patients who suffer conducted to examine possible as- as chewing gum and nail biting were does not exist. However, there are indications that TMD and headaches may be intertwined.
from TMD is strong.12 However, there sociations between TMD and occlu- also considered. As physical exercise is controversy in the scientific litera- sal interferences with the etiology of plays a major role in medical preven- Purpose. The purpose of this study was to identify the presence or absence of an association of occlusal interferences,
ture regarding the etiology of TMD. headache. Over an 11 month period tion therapy, the patients' activities parafunction, TMD, or physiologic, muscular, or prosthodontic factors with the occurrence of headache.
To date, controlled studies have failed (October 2008 until August 2009), were screened concerning the type, Material and methods. In a private practice population of 1031 subjects (436 men and 595 women, mean age 49.6
to prove an association between mal- 1031 patients were questioned and frequency, and duration of workouts, years) the demographic parameters, headache and general pain history, habits and general personal information were occlusion, parafunction, dental wear, examined. The study population con- even though there is limited evidence recorded. Clinical examination for dental, muscular, and temporomandibular joint pathology was accomplished. Data TMD, and headache.8, 23-30 Interest- sisted of the patient base of an oral that physical exercise has a protec- were statistically analyzed using the Mann-Whitney U, Kruskal-Wallis, and Chi-Square tests (α=.05). A multinomial ingly, treatment of headache patients and maxillofacial surgery practice in tive effect on the etiology of a head- logistic regression analysis was performed with respect to confounding variables.
who display coincident malocclusion Ansbach, Germany. All patients, with- ache.2,49,50,53,54 with occlusal splints seems to allevi- out exception, who presented and The patients answered the ques- Results. Headache affliction was found to affect women more frequently than men (1.7:1). Students and non aca-
ate their burden.31-33 consented to participate during the tionnaire in the absence of the exam- demics were more prone to suffer from headache. Parafunction (P=.001), TMD (P=.001) and gross differences The International Headache So- 11 month period, were included in iner. Subsequent to the questionnaire, between centric occlusion and maximum intercuspation of more than a 3 mm visible track marked with 8 µm articu- ciety (IHS) has published criteria the study. However, after evaluation the patients underwent thorough lation foil (P=.001) significantly influenced the presence of headache. Headache intensity and frequency decreased for diagnosing the subgroups of of the headache diagnoses, patients dental, orofacial, and cervical exami- with age. While tension-type headache was most frequently diagnosed, the parameters studied were not significantly headache.34-35 Primary and second- suffering from secondary headache nation. The examinations were per- associated with one certain headache diagnosis more frequently than others.
ary headache forms are defined, had to be excluded as the sparseness formed by 3 general dentists and one Conclusions. Stomatognathic factors of TMD, parafunction, and gross differences between centric occlusion and
and patients can be diagnosed with of secondary headache subjects ruled oral and maxillofacial surgeon, all of maximum intercuspation of more than 3 mm are associated with headache. These findings should be interpreted with more than one headache type. Both out reasonable statistical evaluation. whom examined the same parameters caution due to the cross-sectional nature of this study. (J Prosthet Dent 2011;105:410-417) migraine headache and tension-type The authors received informed con- according to a predetermined stan-headache (TTH) have been associ- sent from all patients who took part dard to which all examiners were cali-ated with TMD.1 Surprisingly, pa- in the study. Parental consent was brated prior to the study. Calibration Clinical Implications tients that were diagnosed with TTH obtained for all patients under 18 of the examiners was assured by mod- This study suggests that headaches are associated with TMD and displayed the least prevalence of si- years of age. All patients completed el examinations, which were demon-multaneous TMD, but patients with a standardized, 2-part questionnaire. strated and controlled by the most occlusal discrepancies, but it does not suggest that their treatment concurrent diagnoses of migraine The first part was completed by the experienced examiner, the oral and may reduce the occurrence of pain.
headache and TTH showed the high- patient; the second part concerning maxillofacial surgeon. The examiners est correlation with TMD.1 The reason occlusion, the state of muscles, and who were assigned patients without for that is still unclear. The literature questions about TMD was completed systematic randomization, examined aPrivate Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
states that the trigeminal nuclei areas by the examiners. The questions were and recorded various oral and tem- bPrivate Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
for proprioceptive, mechanorecep- designed in accordance with the Ger- poromandibular joint (TMJ) dysfunc- cProfessor, Director, Graduate Prosthodontics Division, University of Texas Health Science Center at San Antonio.
tive, and pain sensations in the spinal man version of the Research Diagnos- tion parameters.2 The TMJ was exam- dPrivate Practice, Rochester; Assistant Professor, Prosthodontic Residency University of Rochester, Eastman Institute for Oral cord are in close proximity.36-43 Com- tic Criteria for Temporomandibular ined for clicking and crepitus, pain Health.
eDepartment Director, Department of Restorative Dentistry, Phillips-University Marburg.
plex mechanisms such as homo- and Disorders (RDC/TMD) 47 and the IHS (both spontaneous and on TMJ load- f Professor, Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
heterosynaptic plasticity, sensitiza- criteria.34,35 Furthermore, the form in- ing), mandibular range of motion, and The Journal of Prosthetic Dentistry Headache is a widespread ail- tion and modulation via interneuro- cluded data such as gender, age, edu- Prevalence and association of ment. Both temporomandibular joint nal input may eventually trigger an cation, and socioeconomic status as headaches, temporomandibular joint disorders (TMD) and headache have overlap of spinal innervation from the influence of demographic factors major impacts on the quality of life.1 muscular proprioceptive areas to pain on the etiology of TMD and headache disorders, and occlusal interferences Studies report a lifetime prevalence of areas.38,40-43 is scientifically controversial.2,48-51 every headache type for 69% of men As stated, clinical practice experi- Consumption of substances such as and 88% of women.2-9 Lupoli and ence suggests that headache and den- alcohol, caffeine, and nicotine, and M. Troeltzsch, DMD, MD,a M. Troeltzsch, DMD,b R.J. Cronin,
Lockey10 report that 10 million Ameri- tal pathology are intertwined. Never- the presence of psychological factors DDS, MS,c A.H. Brodine, DMD,d R. Frankenberger, DMD, PhD,e
cans cope with frequent headaches. theless, only a few studies44-46 indicate including fear of the future, depres-Although the etiological factors of such a correlation. The purpose of sion, psychiatric therapy, or use of an- and K. Messlinger, MD, PhDf
headaches are not fully understood, this study was to identify the presence tipsychotic drugs were also analyzed Friedrich Alexander University Erlangen-Nuremberg, Erlangen, vascular/neurologic factors, age, gen- or absence of an association of occlu- as the literature indicates that there Germany; University of Texas Health Science Center at San der, and muscular hypertension of sal interferences, parafunction, TMD, may be an influence.52the masticatory and cervical muscles or physiologic, muscular, or prosth- Each patient's medical history was Antonio, San Antonio, Texas; University of Rochester, Eastman are reported.2,11 Furthermore, dis- odontic factors with the occurrence queried for cardiovascular disease, Institute for Oral Health, Rochester, NY; Phillips-University orders in the temporomandibular of headache.
hypertension, diabetes, orthopedic joint region have been suspected and problems, and lung, kidney, and liver Marburg, Germany, Ansbach, Germany.
shown to influence the etiology, fre- MATERIAL AND METHODS disease because these were consid- quency, intensity, and chronicity of ered relevant after thorough literature Statement of problem. Although an interaction of malocclusion, parafunction, and temporomandibular joint disor-
headache.10,12-22 In fact, the correla- This cross-sectional study was review.2 The prevalence of habits such ders (TMD) can be inferred from the experience of daily practice, scientific evidence to corroborate this hypothesis tion for headache patients who suffer conducted to examine possible as- as chewing gum and nail biting were does not exist. However, there are indications that TMD and headaches may be intertwined.
from TMD is strong.12 However, there sociations between TMD and occlu- also considered. As physical exercise is controversy in the scientific litera- sal interferences with the etiology of plays a major role in medical preven- Purpose. The purpose of this study was to identify the presence or absence of an association of occlusal interferences,
ture regarding the etiology of TMD. headache. Over an 11 month period tion therapy, the patients' activities parafunction, TMD, or physiologic, muscular, or prosthodontic factors with the occurrence of headache.
To date, controlled studies have failed (October 2008 until August 2009), were screened concerning the type, Material and methods. In a private practice population of 1031 subjects (436 men and 595 women, mean age 49.6
to prove an association between mal- 1031 patients were questioned and frequency, and duration of workouts, years) the demographic parameters, headache and general pain history, habits and general personal information were occlusion, parafunction, dental wear, examined. The study population con- even though there is limited evidence recorded. Clinical examination for dental, muscular, and temporomandibular joint pathology was accomplished. Data TMD, and headache.8, 23-30 Interest- sisted of the patient base of an oral that physical exercise has a protec- were statistically analyzed using the Mann-Whitney U, Kruskal-Wallis, and Chi-Square tests (α=.05). A multinomial ingly, treatment of headache patients and maxillofacial surgery practice in tive effect on the etiology of a head- logistic regression analysis was performed with respect to confounding variables.
who display coincident malocclusion Ansbach, Germany. All patients, with- ache.2,49,50,53,54 with occlusal splints seems to allevi- out exception, who presented and The patients answered the ques- Results. Headache affliction was found to affect women more frequently than men (1.7:1). Students and non aca-
ate their burden.31-33 consented to participate during the tionnaire in the absence of the exam- demics were more prone to suffer from headache. Parafunction (P=.001), TMD (P=.001) and gross differences The International Headache So- 11 month period, were included in iner. Subsequent to the questionnaire, between centric occlusion and maximum intercuspation of more than a 3 mm visible track marked with 8 µm articu- ciety (IHS) has published criteria the study. However, after evaluation the patients underwent thorough lation foil (P=.001) significantly influenced the presence of headache. Headache intensity and frequency decreased for diagnosing the subgroups of of the headache diagnoses, patients dental, orofacial, and cervical exami- with age. While tension-type headache was most frequently diagnosed, the parameters studied were not significantly headache.34-35 Primary and second- suffering from secondary headache nation. The examinations were per- associated with one certain headache diagnosis more frequently than others.
ary headache forms are defined, had to be excluded as the sparseness formed by 3 general dentists and one Conclusions. Stomatognathic factors of TMD, parafunction, and gross differences between centric occlusion and
and patients can be diagnosed with of secondary headache subjects ruled oral and maxillofacial surgeon, all of maximum intercuspation of more than 3 mm are associated with headache. These findings should be interpreted with more than one headache type. Both out reasonable statistical evaluation. whom examined the same parameters caution due to the cross-sectional nature of this study. (J Prosthet Dent 2011;105:410-417) migraine headache and tension-type The authors received informed con- according to a predetermined stan-headache (TTH) have been associ- sent from all patients who took part dard to which all examiners were cali-ated with TMD.1 Surprisingly, pa- in the study. Parental consent was brated prior to the study. Calibration Clinical Implications tients that were diagnosed with TTH obtained for all patients under 18 of the examiners was assured by mod- This study suggests that headaches are associated with TMD and displayed the least prevalence of si- years of age. All patients completed el examinations, which were demon-multaneous TMD, but patients with a standardized, 2-part questionnaire. strated and controlled by the most occlusal discrepancies, but it does not suggest that their treatment concurrent diagnoses of migraine The first part was completed by the experienced examiner, the oral and may reduce the occurrence of pain.
headache and TTH showed the high- patient; the second part concerning maxillofacial surgeon. The examiners est correlation with TMD.1 The reason occlusion, the state of muscles, and who were assigned patients without for that is still unclear. The literature questions about TMD was completed systematic randomization, examined aPrivate Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
states that the trigeminal nuclei areas by the examiners. The questions were and recorded various oral and tem- bPrivate Practice, Ansbach, Germany; Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
for proprioceptive, mechanorecep- designed in accordance with the Ger- poromandibular joint (TMJ) dysfunc- cProfessor, Director, Graduate Prosthodontics Division, University of Texas Health Science Center at San Antonio.
tive, and pain sensations in the spinal man version of the Research Diagnos- tion parameters.2 The TMJ was exam- dPrivate Practice, Rochester; Assistant Professor, Prosthodontic Residency University of Rochester, Eastman Institute for Oral cord are in close proximity.36-43 Com- tic Criteria for Temporomandibular ined for clicking and crepitus, pain Health.
eDepartment Director, Department of Restorative Dentistry, Phillips-University Marburg.
plex mechanisms such as homo- and Disorders (RDC/TMD) 47 and the IHS (both spontaneous and on TMJ load- f Professor, Department of Physiology and Pathophysiology, University Erlangen-Nuremberg.
heterosynaptic plasticity, sensitiza- criteria.34,35 Furthermore, the form in- ing), mandibular range of motion, and The Journal of Prosthetic Dentistry Volume 105 Issue 6 mandibular deviation upon mouth single variables were combined in treatment. However, 240 patients re- opening and during mandibular pro- groups to facilitate statistical analysis.
Table II. Gender distribution of headache, TMD and ported that they experienced psycho- trusion. The masseteric, temporal, del- The statistical analysis was per- In total, 1031 patients were ex- psychiatric diagnoses (Chi-Squared analysis) logical impairment. toid, trapezius, mylohoid, geniohyoid, formed using statistical software amined: 436 (42.3%) men and 595 While 334 patients felt physically digastric, occipital, and medial and (SPSS for Windows, 2009, Release (57.7%) women. The mean age was tense, only 33 had ever been in treat- lateral pterygoid muscles were exam- 17.0; SPSS Inc, Chicago, Ill). Interval 49.6 (±13.2) years and 257 patients ment for muscle relaxation. The ex- ined for myogenic pain (both sponta- scale data were examined using the were younger than 30 years, 474 be- amination of the facial and cervical neous and on the application of pres- Kruskal-Wallis H test. Where neces- tween 30 and 60 years and 288 older muscle groups (deltoid, trapezius, sure) and trigger points. sary, analysis by pairs was accom- than 60 years. Table I summarizes the mylohoid, geniohyoid, digastric, oc- A history of bruxism, dental at- plished with the Mann-Whitney U primary aspects of examined demo- cipital, medial and lateral pterygoid trition, tooth impressions in the mu- test. The Chi-square test was used for graphic factors. Smoking was admit- muscles) revealed pathology (myo- cosa of the tongue and cheek, as well nominal scaled data; the Phi and Cra- ted by 209 patients, 379 admitted geloses, pain, sensitive trigger points, as recession and non carious cervical mer's V correlation coefficients were consuming alcohol frequently (more or combinations) in 436 patients. Af- lesions (NCCL) were recorded. Wear computed to identify possible general than once a week), and 524 drank ter examination, 695 patients were di- Movement restraint was evaluated intraorally according to correlations; multinomial logistic re- coffee regularly. Stimulant consump- agnosed with some type of headache. Mandible deviation criteria defined by Pullinger and Selig- gression analysis was performed to tion was equally distributed between Tension-type headache (TTH) was man.55 The presence of bruxism was assess the individual association of genders. In response to physical activ- most frequently diagnosed (48%), determined by report of the patient each variable on headache, and values ity questions, 675 subjects reported followed by migraine (1%). Only 85 and by clinical signs such as consis- of α=.05 were considered statistically that they exercised regularly. Of these, Severe depression patients showed signs of both TTH tent occlusal wear patterns on both significant. The odds ratios (OR) were 262 exercised less than 2 hours per and migraine. Some type of TMD was natural teeth and restorations. The calculated, and the literature suggests week, 265 between 2 and 4 hours found in 409 patients. Table II dis- prosthodontic and restorative state that an OR ≥ 2 is considered clinically and 148 more than 4 hours. Psycho- plays the distribution of headache, of the patient was considered. The significant.57 logically, 86 patients suffered from se- P<.05 indicates significant difference TMD diagnoses, and psychological existence and the condition of fixed vere depression or were in psychiatric impairment by gender. and removable prostheses were not- Table III. Detailed description of dental/parafunctional/prosthodontic findings TMD were found significantly ed. Detection of premature contacts, Table I. Distribution of patients according to selected demographic factors more often in patients where mus- found by bimanual manipulation, in- cular pathology or parafunction, dicated that maximum intercuspation specifically bruxism and incisal wear, (MI) was inconsistent with centric oc- were detected. Regression analysis clusion (CO).56 The examiners record- disclosed significant associations. ed any tracks between the premature Strong odds ratios were computed for Tooth impressions in tongue/cheek mucosa centric occlusion contact and the MI. $31,750 – $63,500 the variables: greater than 30 years of Incisal wear only If a track longer than 3 mm between $63,500 – $127,000 age (OR 4.29), a current student (OR Premolar/molar wear only the premature contacts in CO and MI 7.09), detection of any stated mus- Incisal and premolar/molar wear position could clearly be identified, it Refused to answer cular pathologies (OR 4.87), bruxism Bruxers and incisal wear was considered clinically significant. (OR 7.9), and horizontal deviations Bruxers and incisal and premolar/molar wear Prestudy calibration of the authors between CO and MI (OR 25.9). revealed that tracks less than 3 mm University/col ege degree While the prevalence of headache could not be reproducibly identified Nonacademic career Patients with crowns only decreased with age, TMD occurrence by all examiners. The tracks were re- Student (high school/college/university) Patients with fixed dental prostheses (3-unit and more) only was highest in the age group between corded by using a double layer of ar- Patients with removable prostheses 30 and 60 years as shown in Table III. ticulation foil (Arti-Fol 8 µm; Bausch, Retired and university/col ege degree Patients with fixed and removable prostheses Although not statistically significant, Cologne, Germany). Finally, the oc- Retired and nonacademic career Patients with a combination of restorations/prostheses TMD problems were more commonly clusal vertical dimension and centric diagnosed on the left side. Signs of relation deviations were recorded. General Satisfaction in Life
parafunction and wear were displayed No parafunctional habits For the measurement of the verti- in 613 patients, while 408 patients cal dimension, a Boley caliper gauge Yes, with reservations had single or multiple unit fixed pros- (Miltex Inc, York, Pa) was used. If the theses. Parafunctional habits were re- Gum chewing and nail biting difference between maximum inter- ported for 339 patients. Incorrect oc- cuspation and the mandibular resting Fear of Future
clusal vertical dimension was found in position was greater than 4 mm, it Further Intricacies of the Stomatognathic System
44 patients.
was described as incorrect. Difference between MI and mandibular resting The majority of headache patients Headache diagnoses, if applica- position ≥ 4 mm did not show any statistically signifi- ble, were recorded according to IHS Difference between MI and CO ≥ 3 mm cant signs of psychological impair- criteria34,35 and where appropriate, ment. Significantly more patients The Journal of Prosthetic Dentistry Volume 105 Issue 6 mandibular deviation upon mouth single variables were combined in treatment. However, 240 patients re- opening and during mandibular pro- groups to facilitate statistical analysis.
Table II. Gender distribution of headache, TMD and ported that they experienced psycho- trusion. The masseteric, temporal, del- The statistical analysis was per- In total, 1031 patients were ex- psychiatric diagnoses (Chi-Squared analysis) logical impairment. toid, trapezius, mylohoid, geniohyoid, formed using statistical software amined: 436 (42.3%) men and 595 While 334 patients felt physically digastric, occipital, and medial and (SPSS for Windows, 2009, Release (57.7%) women. The mean age was tense, only 33 had ever been in treat- lateral pterygoid muscles were exam- 17.0; SPSS Inc, Chicago, Ill). Interval 49.6 (±13.2) years and 257 patients ment for muscle relaxation. The ex- ined for myogenic pain (both sponta- scale data were examined using the were younger than 30 years, 474 be- amination of the facial and cervical neous and on the application of pres- Kruskal-Wallis H test. Where neces- tween 30 and 60 years and 288 older muscle groups (deltoid, trapezius, sure) and trigger points. sary, analysis by pairs was accom- than 60 years. Table I summarizes the mylohoid, geniohyoid, digastric, oc- A history of bruxism, dental at- plished with the Mann-Whitney U primary aspects of examined demo- cipital, medial and lateral pterygoid trition, tooth impressions in the mu- test. The Chi-square test was used for graphic factors. Smoking was admit- muscles) revealed pathology (myo- cosa of the tongue and cheek, as well nominal scaled data; the Phi and Cra- ted by 209 patients, 379 admitted geloses, pain, sensitive trigger points, as recession and non carious cervical mer's V correlation coefficients were consuming alcohol frequently (more or combinations) in 436 patients. Af- lesions (NCCL) were recorded. Wear computed to identify possible general than once a week), and 524 drank ter examination, 695 patients were di- Movement restraint was evaluated intraorally according to correlations; multinomial logistic re- coffee regularly. Stimulant consump- agnosed with some type of headache. Mandible deviation criteria defined by Pullinger and Selig- gression analysis was performed to tion was equally distributed between Tension-type headache (TTH) was man.55 The presence of bruxism was assess the individual association of genders. In response to physical activ- most frequently diagnosed (48%), determined by report of the patient each variable on headache, and values ity questions, 675 subjects reported followed by migraine (1%). Only 85 and by clinical signs such as consis- of α=.05 were considered statistically that they exercised regularly. Of these, Severe depression patients showed signs of both TTH tent occlusal wear patterns on both significant. The odds ratios (OR) were 262 exercised less than 2 hours per and migraine. Some type of TMD was natural teeth and restorations. The calculated, and the literature suggests week, 265 between 2 and 4 hours found in 409 patients. Table II dis- prosthodontic and restorative state that an OR ≥ 2 is considered clinically and 148 more than 4 hours. Psycho- plays the distribution of headache, of the patient was considered. The significant.57 logically, 86 patients suffered from se- P<.05 indicates significant difference TMD diagnoses, and psychological existence and the condition of fixed vere depression or were in psychiatric impairment by gender. and removable prostheses were not- Table III. Detailed description of dental/parafunctional/prosthodontic findings TMD were found significantly ed. Detection of premature contacts, Table I. Distribution of patients according to selected demographic factors more often in patients where mus- found by bimanual manipulation, in- cular pathology or parafunction, dicated that maximum intercuspation specifically bruxism and incisal wear, (MI) was inconsistent with centric oc- were detected. Regression analysis clusion (CO).56 The examiners record- disclosed significant associations. ed any tracks between the premature Strong odds ratios were computed for Tooth impressions in tongue/cheek mucosa centric occlusion contact and the MI. $31,750 – $63,500 the variables: greater than 30 years of Incisal wear only If a track longer than 3 mm between $63,500 – $127,000 age (OR 4.29), a current student (OR Premolar/molar wear only the premature contacts in CO and MI 7.09), detection of any stated mus- Incisal and premolar/molar wear position could clearly be identified, it Refused to answer cular pathologies (OR 4.87), bruxism Bruxers and incisal wear was considered clinically significant. (OR 7.9), and horizontal deviations Bruxers and incisal and premolar/molar wear Prestudy calibration of the authors between CO and MI (OR 25.9). revealed that tracks less than 3 mm University/col ege degree While the prevalence of headache could not be reproducibly identified Nonacademic career Patients with crowns only decreased with age, TMD occurrence by all examiners. The tracks were re- Student (high school/college/university) Patients with fixed dental prostheses (3-unit and more) only was highest in the age group between corded by using a double layer of ar- Patients with removable prostheses 30 and 60 years as shown in Table III. ticulation foil (Arti-Fol 8 µm; Bausch, Retired and university/col ege degree Patients with fixed and removable prostheses Although not statistically significant, Cologne, Germany). Finally, the oc- Retired and nonacademic career Patients with a combination of restorations/prostheses TMD problems were more commonly clusal vertical dimension and centric diagnosed on the left side. Signs of relation deviations were recorded. General Satisfaction in Life
parafunction and wear were displayed No parafunctional habits For the measurement of the verti- in 613 patients, while 408 patients cal dimension, a Boley caliper gauge Yes, with reservations had single or multiple unit fixed pros- (Miltex Inc, York, Pa) was used. If the theses. Parafunctional habits were re- Gum chewing and nail biting difference between maximum inter- ported for 339 patients. Incorrect oc- cuspation and the mandibular resting Fear of Future
clusal vertical dimension was found in position was greater than 4 mm, it Further Intricacies of the Stomatognathic System
44 patients.
was described as incorrect. Difference between MI and mandibular resting The majority of headache patients Headache diagnoses, if applica- position ≥ 4 mm did not show any statistically signifi- ble, were recorded according to IHS Difference between MI and CO ≥ 3 mm cant signs of psychological impair- criteria34,35 and where appropriate, ment. Significantly more patients The Journal of Prosthetic Dentistry Volume 105 Issue 6 gether.10,12,13,16,18,20-22 In the examined Table IV. Total numbers presented by outcome variable of patients suffering from headache Table V. Odds ratios and corresponding P - Values of significant vari- population, TMD were influenced by ables for prevalence of headache (95% confidence interval in parenthe- muscular pathology and parafunc- ses), (referent category always event of suffering from primary head- tion. Although there is agreement ache) generated in multinominal logistic regression analysis that muscular pathology impacts TMD,30 the contention that parafunc- tion has an influence on TMD is dis-puted by the data that Seligman and Age 14 – 30 years Pullinger,25 De Meyer et al,8 and Schi- Age 31 – 60 years erz et al23 provided. The contention Age 14 – 30 years is supported by the studies of Celic Age 31 – 60 years et al,36 Nagamatsu-Sakaguchi et al,45 Nonacademic career and Scrivani et al.46 More well-con-trolled studies are needed to clarify Nonacademic career Student (high school/ this issue. Consistent with previous col ege/university) studies,26-28 the current study found Student (high school/college/university) that neither malocclusion nor gross Muscular pathology differences between MI and CO were TMJ pathology (except clicking) (myogenic pain/trigger significantly more prevalent in TMD patients. Surprisingly, parafunction Muscular pathology was strongly associated with the prev- (myogenous pain/trigger points/combinations) alence of headache; and patients with a gross difference between MI and Absence of TMJ pathology Bruxism and incisal and CO had the highest coincidence with premolar/molar wear primary headache. This is remarkable since an association between TMD Horizontal differences and headache is presumed, despite Bruxism and incisal and premolar/molar wear between CO and MI various study results that concluded greater than 3 mm there is either no or only a weak rela- Horizontal differences between CO and tionship between occlusal parameters MI greater than 3mm Moderate consumption and TMD.5,12,24,29,30 Extensive litera- of alcohol/coffee ture review found only 2 studies that Moderate consumption of alcohol/coffee reported similar results.9,44 Neverthe-less, there is evidence in the literature who felt physically tense (28.4%), or combination. The highest frequency P<.05 indicates significant difference that headache patients are self-re- were diagnosed with muscular (36%) of occurrence of TTH and migraine cally tense, and who simultaneously in TMD patients,5,13,20 cause continu- ported bruxers,14, 16 and both bruxing or TMJ pathology (14%) also suffered headache was observed with severe The purpose of the study was to exhibited muscular pathology or TMD. ous strong mechanoreceptive input to and headache decrease with age.2,3,8,9 from recurrent headache. The com- parafunction and horizontal differ- explore associations between TMD, The effect of muscle pathology many processing neurons in the spinal Treatment with occlusal splints has puting of correlation coefficients and ences longer than 3 mm between aberrant stomatognathic function on headache has been previously pub- cord.41 Among those are a wide dy- been reported to reduce headache in- regression analysis showed significant MI and CO, with a highly significant and the occurrence of headache. Cor- lished.5,13,20 Graff-Radford19 contends namic range of neurons that not only tensity and frequency.31-33 associations among age, gender, edu- (P≤.001) association. Healthy TMJs relations can be assumed due to the that TMD elicit or exacerbate headache receive diverse input, but also project Ciancaglini et al9 asserted that cational aspects, stimulant consump- and moderate consumption of stim- findings of the study. Therefore, the because of an overlap of innervations to different processing neurons, in- lengthy muscular stimulation by para- tion, TMD, horizontal differences be- ulants seemed to have a protective hypothesis that there is an interrela- with the trigeminal nerve. As previ- cluding pain neurons.42,43 Sustained function may lower the thresholds of tween MI and CO greater than 3 mm, effect on the evolution of headache. tionship between headache, TMD, ously stated, the trigeminal nuclei for neuronal stimulation triggers mecha- pain sensation. Congruent findings and masticatory and cervical muscle Table IV and V depict descriptive sta- and occlusal interferences is ac- mechanoreceptive, proprioceptive, nisms of synaptic plasticity,38 and were published by Arima et al58 and pathology with the appearance of tistics by relevant outcome variables cepted. Of the 1031 patients in this and pain sensations are in close prox- eventually new synaptic pathways are Christensen et al.59 An independent headache. Variables such as young and the odds ratios for the prevalence study, 67.4% claimed to suffer from imity.36,37,40 Interneurons between the created.43 That may explain the occur- relation between occlusal factors age, female gender, educational level, of headaches. frequent headaches. As reported pre- different nuclei areas, namely spinal rence and perpetuation of headache and headache is plausible. However, severe parafunction, muscle or TMJ The data did not indicate any viously,24,6,7,35 this study demonstrated trigeminal nuclei oralis, interpolaris, in patients whose stomatognathic as previously stated, this study was pathology, and greater than 3 mm dif- significant prevalence of headaches that tension-type headache was most and caudalis, have been identified, system is disturbed in any way. The a cross-sectional study without sys- ference between CO and MI correlated in patients who were suffering from frequently diagnosed, women were and their importance in the pro- relation between TMD and the oc- tematic randomization. Therefore, se- with a higher prevalence of every kind chronic pain in any region of the body significantly more affected by primary cessing of orofacial proprioceptive currence of headache is still a matter lection bias cannot be ruled out and of headache, and increased the risk of other than head, neck, face, and the headache, headache decreased with and pain information has been de- of scientific contention, even though cause-effect conclusions must be con- the occurrence of migraine and ten- stomatognathic system. age, and there was a higher prevalence scribed.41-43 Tense muscles, inflamed there is increasing evidence that TMD sidered with care. To explore the as- sion-type headache, separately and in of headache in patients who felt physi- TMJ structures, or bruxism, detected and headache frequently appear to- sociations of occlusion headache and The Journal of Prosthetic Dentistry Volume 105 Issue 6 gether.10,12,13,16,18,20-22 In the examined Table IV. Total numbers presented by outcome variable of patients suffering from headache Table V. Odds ratios and corresponding P - Values of significant vari- population, TMD were influenced by ables for prevalence of headache (95% confidence interval in parenthe- muscular pathology and parafunc- ses), (referent category always event of suffering from primary head- tion. Although there is agreement ache) generated in multinominal logistic regression analysis that muscular pathology impacts TMD,30 the contention that parafunc- tion has an influence on TMD is dis-puted by the data that Seligman and Age 14 – 30 years Pullinger,25 De Meyer et al,8 and Schi- Age 31 – 60 years erz et al23 provided. The contention Age 14 – 30 years is supported by the studies of Celic Age 31 – 60 years et al,36 Nagamatsu-Sakaguchi et al,45 Nonacademic career and Scrivani et al.46 More well-con-trolled studies are needed to clarify Nonacademic career Student (high school/ this issue. Consistent with previous col ege/university) studies,26-28 the current study found Student (high school/college/university) that neither malocclusion nor gross Muscular pathology differences between MI and CO were TMJ pathology (except clicking) (myogenic pain/trigger significantly more prevalent in TMD patients. Surprisingly, parafunction Muscular pathology was strongly associated with the prev- (myogenous pain/trigger points/combinations) alence of headache; and patients with a gross difference between MI and Absence of TMJ pathology Bruxism and incisal and CO had the highest coincidence with premolar/molar wear primary headache. This is remarkable since an association between TMD Horizontal differences and headache is presumed, despite Bruxism and incisal and premolar/molar wear between CO and MI various study results that concluded greater than 3 mm there is either no or only a weak rela- Horizontal differences between CO and tionship between occlusal parameters MI greater than 3mm Moderate consumption and TMD.5,12,24,29,30 Extensive litera- of alcohol/coffee ture review found only 2 studies that Moderate consumption of alcohol/coffee reported similar results.9,44 Neverthe-less, there is evidence in the literature who felt physically tense (28.4%), or combination. The highest frequency P<.05 indicates significant difference that headache patients are self-re- were diagnosed with muscular (36%) of occurrence of TTH and migraine cally tense, and who simultaneously in TMD patients,5,13,20 cause continu- ported bruxers,14, 16 and both bruxing or TMJ pathology (14%) also suffered headache was observed with severe The purpose of the study was to exhibited muscular pathology or TMD. ous strong mechanoreceptive input to and headache decrease with age.2,3,8,9 from recurrent headache. The com- parafunction and horizontal differ- explore associations between TMD, The effect of muscle pathology many processing neurons in the spinal Treatment with occlusal splints has puting of correlation coefficients and ences longer than 3 mm between aberrant stomatognathic function on headache has been previously pub- cord.41 Among those are a wide dy- been reported to reduce headache in- regression analysis showed significant MI and CO, with a highly significant and the occurrence of headache. Cor- lished.5,13,20 Graff-Radford19 contends namic range of neurons that not only tensity and frequency.31-33 associations among age, gender, edu- (P≤.001) association. Healthy TMJs relations can be assumed due to the that TMD elicit or exacerbate headache receive diverse input, but also project Ciancaglini et al9 asserted that cational aspects, stimulant consump- and moderate consumption of stim- findings of the study. Therefore, the because of an overlap of innervations to different processing neurons, in- lengthy muscular stimulation by para- tion, TMD, horizontal differences be- ulants seemed to have a protective hypothesis that there is an interrela- with the trigeminal nerve. As previ- cluding pain neurons.42,43 Sustained function may lower the thresholds of tween MI and CO greater than 3 mm, effect on the evolution of headache. tionship between headache, TMD, ously stated, the trigeminal nuclei for neuronal stimulation triggers mecha- pain sensation. Congruent findings and masticatory and cervical muscle Table IV and V depict descriptive sta- and occlusal interferences is ac- mechanoreceptive, proprioceptive, nisms of synaptic plasticity,38 and were published by Arima et al58 and pathology with the appearance of tistics by relevant outcome variables cepted. Of the 1031 patients in this and pain sensations are in close prox- eventually new synaptic pathways are Christensen et al.59 An independent headache. Variables such as young and the odds ratios for the prevalence study, 67.4% claimed to suffer from imity.36,37,40 Interneurons between the created.43 That may explain the occur- relation between occlusal factors age, female gender, educational level, of headaches. frequent headaches. As reported pre- different nuclei areas, namely spinal rence and perpetuation of headache and headache is plausible. However, severe parafunction, muscle or TMJ The data did not indicate any viously,24,6,7,35 this study demonstrated trigeminal nuclei oralis, interpolaris, in patients whose stomatognathic as previously stated, this study was pathology, and greater than 3 mm dif- significant prevalence of headaches that tension-type headache was most and caudalis, have been identified, system is disturbed in any way. The a cross-sectional study without sys- ference between CO and MI correlated in patients who were suffering from frequently diagnosed, women were and their importance in the pro- relation between TMD and the oc- tematic randomization. Therefore, se- with a higher prevalence of every kind chronic pain in any region of the body significantly more affected by primary cessing of orofacial proprioceptive currence of headache is still a matter lection bias cannot be ruled out and of headache, and increased the risk of other than head, neck, face, and the headache, headache decreased with and pain information has been de- of scientific contention, even though cause-effect conclusions must be con- the occurrence of migraine and ten- stomatognathic system. age, and there was a higher prevalence scribed.41-43 Tense muscles, inflamed there is increasing evidence that TMD sidered with care. To explore the as- sion-type headache, separately and in of headache in patients who felt physi- TMJ structures, or bruxism, detected and headache frequently appear to- sociations of occlusion headache and The Journal of Prosthetic Dentistry Volume 105 Issue 6 TMD further, well-controlled random- 12.Bertoli FM, Antoniuk SA, Bruck I, Xavier 28.Gesch D, Bernhardt O, Kirbschus A. Asso- 40.Sessle BJ, Hu JW, Amano N, Zhong G. Con- 51.Hagen K, Thoresen K, Stovner LJ, Zwart JA. ized longitudinal studies are necessary.
GR, Rodrigues DC, Losso EM. Evaluation ciation of malocclusion and functional oc- vergence of cutaneous, tooth pulp, visceral, High dietary caffeine consumption is asso- of the signs and symptoms of temporoman- clusion with temporomandibular disorders neck and muscle afferents onto nociceptive ciated with a modest increase in headache Furthermore, consistent with the Within the limitations of this study dibular disorders in children with head- (TMD) in adults: a systematic review of and non-nociceptive neurones in trigemi- prevalence: results from the Head-HUNT literature,2,49,50,53,54 physical exercise, the following conclusions were drawn: aches. Arq Neuropsiquiatr 2007;65:251-5.
population-based studies. Quintessence Int nal subnucleus caudalis (medullary dorsal Study. J Headache Pain 2009;10:153-9.
and psychological or general health 1. Parafunction and differences 13.Svensson P. Muscle pain in the head: over- horn) and its implications for referred pain. 52.Yap AU, Dworkin SF, Chua EK, List T, Tan lap between temporomandibular disorders 29.Michelotti A, Farella M, Gallo LM, Veltri KB, Tan HH. Prevalence of temporoman- status did not influence the preva- between CO and MI, identified by and tension-type headaches. Curr Opin A, Palla S, Martina R. Effect of occlusal 41.Broton JG, Hu JW, Sessle BJ. Effects of dibular disorder subtypes, psychologic lence of headache. Of the analyzed clearly visible tracks longer than 3 interference on habitual activity of human temporomandibular joint stimulation on distress and psychological dysfunction in demographic factors, only education 14.Molina OF, dos Santos J Jr, Nelson SJ, masseter. J Dent Res 2005;84:644-8.
nociceptive and nonnociceptive neurons Asian patients. J Orofac Pain 2003;17:21-8.
mm, are related to the occurrence of Grossman E. Prevalence of modalities of 30.Kahn J, Tallents RH, Katzberg RW, Ross of the cat's trigeminal subnucleus caudalis 53.Rasmussen BK. Migraine and tension- level showed any effect on the etiol- headache. These findings are in con- headaches and bruxism among patients ME, Murphy WC. Prevalence of dental oc- (medullary dorsal horn). J Neurophysiol type headache in a general population: ogy of headache. These discoveries trast with previously published lit- with craniomandibular disorder. Cranio clusal variables and intraarticular temporo- precipitating factors, female hormones, mandibular disorders: Molar relationship, 42.Hu JW. Response properties of nociceptive sleep pattern and relation to lifestyle. Pain are in contrast with published data. erature and must be interpreted with 15.Molina OF, dos Santos Júnior J, Nelson lateral guidance, and nonworking side and non-nociceptive neurons in the rat's The literature states that demograph- care due to the design of this study.
SJ, Nowlin T. Profile of TMD and bruxer contacts. J Prosthet Dent 1999;82:410-5.
trigeminal subnucleus caudalis (medul- 54.Merikangas KR, Angst J, Isler H. Migraine ic factors, such as income, education, 2. Consistent with previous litera- compared to TMD and nonbruxer patients 31.Kemper JT Jr, Okeson JP. Craniomandibular lary dorsal horn) related to cutaneous and and psychopathology. Ann Gen Psychiatry regarding chief complaint, previous consul- disorders and headaches. J Prosthet Dent deep craniofacial afferent stimulation and general satisfaction and future fears ture, female gender, middle age (30 to tations, modes of therapy, and chronicity. modulation by diffuse noxious inhibitory 55.D'Alessandro R, Benassi G, Lenzi PL. Epi- and hopes are strongly associated 60 years), and muscular pathology, 32.Magnusson T, Carlsson GE. Changes in re- controls. Pain 1990;41:331-45.
demiology of headache in the Republic of with the prevalence of headache.49,51 such as myogenic pain, trigger points, 16.Costa AL, D'Abreu A, Cendes F. Temporo- current headache and mandibular dysfunc- 43.Sessle BJ. Neural mechanisms and path- San Marino. J Neurol Neurosurg Psychiatry mandibular joint internal derangement: tion after various types of dental treatment. ways in craniofacial pain. Can J Neurol Sci Moderate consumption of coffee or combinations have an influence on association with headache, joint effusion, Acta Odontol Scand 1980;38:311-20.
1999;26 Suppl 3:S7-11 56.Pullinger AG, Seligman DA. The degree to and alcohol was less likely to be as- prevalence, frequency, and intensity bruxism, and joint pain. J Contemp Dent 33.Magnusson T, Carlsson GE. A 2½- year 44.Celić R, Jerolimov V, Pandurić J. A study of which attrition characterizes differentiated sociated with headaches. Hagen et of headache.
Pract 2008;9:9-16.
fol ow-up of changes in headache and the influence of occlusal factors and para- patient groups of temporomandibular dis- 17.Wänman A. Craniomandibular disorders mandibular dysfunction after stomatognathic functional habits on the prevalence of signs orders. J Orofac Pain 1993;7:196-208.
al51 reported that high caffeine con- in adolescents. A longitudinal study in an treatment. J Prosthet Dent 1983;49:398-402.
and symptoms of tmd. Int J Prosthodont 57.Keshvad A, WInstanley RB. An appraisal of sumption reduced the risk of frequent urban Swedish population. Swed Dent J 34.Classification and diagnostic criteria for the literature on centric relation. Part III. J headaches in comparison to low caf- Suppl 1987,44:1-61.
headache disorders, cranial neuralgias 45.Nagamatsu-Sakaguchi C, Minakuchi H, Oral Rehabil 2001;28:55-63.
18.Bevilaqua Grossi D, Lipton RB, Bigal ME. and facial pain. Headache Classification Clark GT, Kuboki T. Relationship be- 58.Pullinger AG, Seligman DA. Quantifica- feine consumption, and hinted that 1. Ballegaard V, Thede-Schmidt-Hansen P, Svensson P, Jensen R. Are headache and Temporomandibular disorders and mi- Committee of the International Headache tween the frequency of sleep bruxism and tion and validation of predictive values of caffeine had analgesic properties. In temporomandibular disorders related? A graine chronification. Curr Pain Headache Society. Cephalalgia 1988;8:1-96.
the prevalence of signs and symptoms occlusal variables in temporomandibular the presented data, regression analy- blinded study. Cephalalgia 2008;28:832-41.
Rep 2009;13:314-8.
35.Manzoni GC, Granella F, Sandrini G, Caval- of temporomandibular disorders in an disorders using a multifactorial analysis. J 19.Graff-Radford SB. Temporomandibular lini A, Zanferrari C, Nappi G. Classification adolescent population. Int J Prosthodont Prosthet Dent 2000;83:66-75.
sis showed a protective effect of mild 2. Rasmussen BK. Epidemiology of headache. disorders and headache. Dent Clin North of chronic daily headache by International 59.Arima T, Svensson P, Arendt-Nielsen L. coffee consumption on the etiology 3. Rasmussen BK, Jensen R, Schroll M, Olesen Am 2007;51:129-44.
Headache Society criteria: limits and new 46.Scrivani SJ, Keith DA, Kaban LB. Tem- Experimental grinding in healthy subjects: 20.Cooper BC, Kleinberg I. Relationship of proposals. Cephalalgia 1995;15:37-43.
poromandibular disorders. N Engl J Med a model for postexercise jaw muscle sore- of headache. The authors did not J. Epidemiology of headache in a general population - a prevalence study. J Clin temporomandibular disorders to muscle 36.Hayashi H, Sumino R, Sessle BJ. Functional ness? J Orofac Pain 1999;13:104-14.
identify any association between psy- tension-type headaches and a neuromuscu- organization of trigeminal subnucleus 47.John MT, Hirsch C, Reiber T, Dworkin S. 60.Christensen LV, Tran KT, Mohamed SE. chological impairment and TMD or 4. Bedtsen L, Jensen R. Tension-type head- lar orthosis approach to treatment. Cranio interpolaris: nociceptive and innocuous Translating the research diagnostic criteria Gum chewing and jaw muscle fatigue and afferent inputs, projections to thalamus, for temporomandibular disorders into Ger- pains. J Oral Rehabil 1996;23:424-37.
headache, even though it has previ- ache. Neurol Clin 2009;27:525-35.
5. Bernhardt O, Gesch D, Schwahn C, Mack 21.Schokker RP, Hansson TL, Ansink BJ. Cra- cerebellum, and spinal cord, and descend- man: evaluation of content and process. J ously been described.60 F, Meyer G, John U, et al. Risk factors for niomandibular disorders in headache pa- ing modulation from periaqueductal gray. J Orofac Pain 2006,20:43-52.
Corresponding author: The results of the present study headache, icluding TMD signs and symp- tients. J Craniomandib Disord 1989;3:71-4.
48.Rasmussen BK. Migraine and tension- Dr Matthias Troeltzsch 22.Liljeström MR, Le Bell Y, Anttila P, Aromaa 37.Dessem D, Moritani M, and Ambalavanar type headache in a general population: Maximilianstrasse 5 indicate strong relationships be- toms, and their impact on quality of life. Results of the Study of Health in Pomerania M, Jämsä T, Metsähonkala L, et al. Head- R. Nociceptive Craniofacial Muscle Primary psychosocial factors. Int J Epidemiol tween stomatognathic disorders and (SHIP). Quintessence Int 2005;36 :55-64.
ache children with temporomandibular dis- Afferent Neurons Synapse in Both the Ros- headache. Still, the study has limita- 6. Ciancaglini R, Radaelli G. The relation- orders have several types of pain and other tral and Caudal Brain Stem. J Neurophysiol 49.Waters WE. Migraine: intelligence, social Fax: +49-981-77102 symptoms. Cephalalgia 2005;25:1054-60.
2007; 98:214-223.
class, and familiar prevalence. Br Med J tions. The design is cross-sectional, ship between headache and symptoms of temporomandibular disorder in the general 23.Schierz O, John MT, Schroeder E, Lobbezoo 38.Messlinger K. Migraine: where and how determining the state of the patient population. J Dent 2001,29:93-8.
F. Association between anterior tooth wear does the pain originate? Exp Brain Res 50.Abramson JH, Hopp C, Epstein LM. Mi- Copyright 2011 by the Editorial Council for at only one point in time. The con- 7. Wöber-Bingöl C, Wöber C, Karwautz A, and temporomandibular disorder pain graine and non- migrainous headaches. A The Journal of Prosthetic Dentistry. in a German population. J Prosthet Dent 39.Burstein R, Jakubowski M. Unitary hy- community survey in Jerusalem. J Epidemiol current occurrence of headache and Vesely C, Wagner-Ennsgraber C, Am- minger GP, et al. Diagnosis of headache in pothesis for multiple triggers of the pain Community Health 1980;34:188-93.
other problems may be by chance. No childhood and adolescence: a study in 437 24.John MT, Frank H, Lobbezoo F, Drangsholt and strain of migraine. J Comp Neurol systematic process of randomization patients. Cephalalgia 1995;15:13-21.
M, Dette KE. No association between incisal 8. Pergamalian A, Rudy TE, Zaki HS, Greco tooth wear and temporomandibular disor- was applied; thus, there is a risk of CM. The association between wear facets, ders. J Prosthet Dent 2002;87:197-203.
selection bias. In addition, while the bruxism, and severity of facial pain in pa- 25.Seligman DA, Pullinger AG. The role of functional occlusal relationships in significance may be strong for some tients with temporomandibular disorders. J Prosthet Dent 2003;8:194-200.
temporomandibular disorders: a review. J results, the reader should note the 9. Ciancaglini R, Gherlone EF, Radaelli G. The Craniomandib Disord 1991;5:265-79.
extent of the confidence intervals and relationship of bruxism with craniofacial 26.Marzooq AA, Yatabe M, Ai M. What types of occlusal factors play a role in temporo- the number of patients suffering from pain and symptoms from the masticatory system in the adult population. J Oral mandibular disorders? A literature review. J such problems. Due to the limited Med Dent Sci 1999;46:111-6.
number of subjects who displayed 10. Lupoli TA, Lockey RF. Temporomandibular 27.Hagag G, Yoshida K, Miura H. Occlusion, prosthodontic treatment, and temporo- gross occlusal aberrations, statistical dysfunction: an often overlooked cause of chronic headaches. Ann Allergy Asthma mandibular disorders: a review. J Med Dent significance is weak and the chance Sci 2000;47:61-6.
that these observations are coinci- 11.Kraus S. Temporomandibular disorders, dental cannot be ruled out.
head and orofacial pain: cervical spine considerations. Dent Clin North Am The Journal of Prosthetic Dentistry Volume 105 Issue 6 TMD further, well-controlled random- 12.Bertoli FM, Antoniuk SA, Bruck I, Xavier 28.Gesch D, Bernhardt O, Kirbschus A. Asso- 40.Sessle BJ, Hu JW, Amano N, Zhong G. Con- 51.Hagen K, Thoresen K, Stovner LJ, Zwart JA. ized longitudinal studies are necessary.
GR, Rodrigues DC, Losso EM. Evaluation ciation of malocclusion and functional oc- vergence of cutaneous, tooth pulp, visceral, High dietary caffeine consumption is asso- of the signs and symptoms of temporoman- clusion with temporomandibular disorders neck and muscle afferents onto nociceptive ciated with a modest increase in headache Furthermore, consistent with the Within the limitations of this study dibular disorders in children with head- (TMD) in adults: a systematic review of and non-nociceptive neurones in trigemi- prevalence: results from the Head-HUNT literature,2,49,50,53,54 physical exercise, the following conclusions were drawn: aches. Arq Neuropsiquiatr 2007;65:251-5.
population-based studies. Quintessence Int nal subnucleus caudalis (medullary dorsal Study. J Headache Pain 2009;10:153-9.
and psychological or general health 1. Parafunction and differences 13.Svensson P. Muscle pain in the head: over- horn) and its implications for referred pain. 52.Yap AU, Dworkin SF, Chua EK, List T, Tan lap between temporomandibular disorders 29.Michelotti A, Farella M, Gallo LM, Veltri KB, Tan HH. Prevalence of temporoman- status did not influence the preva- between CO and MI, identified by and tension-type headaches. Curr Opin A, Palla S, Martina R. Effect of occlusal 41.Broton JG, Hu JW, Sessle BJ. Effects of dibular disorder subtypes, psychologic lence of headache. Of the analyzed clearly visible tracks longer than 3 interference on habitual activity of human temporomandibular joint stimulation on distress and psychological dysfunction in demographic factors, only education 14.Molina OF, dos Santos J Jr, Nelson SJ, masseter. J Dent Res 2005;84:644-8.
nociceptive and nonnociceptive neurons Asian patients. J Orofac Pain 2003;17:21-8.
mm, are related to the occurrence of Grossman E. Prevalence of modalities of 30.Kahn J, Tallents RH, Katzberg RW, Ross of the cat's trigeminal subnucleus caudalis 53.Rasmussen BK. Migraine and tension- level showed any effect on the etiol- headache. These findings are in con- headaches and bruxism among patients ME, Murphy WC. Prevalence of dental oc- (medullary dorsal horn). J Neurophysiol type headache in a general population: ogy of headache. These discoveries trast with previously published lit- with craniomandibular disorder. Cranio clusal variables and intraarticular temporo- precipitating factors, female hormones, mandibular disorders: Molar relationship, 42.Hu JW. Response properties of nociceptive sleep pattern and relation to lifestyle. Pain are in contrast with published data. erature and must be interpreted with 15.Molina OF, dos Santos Júnior J, Nelson lateral guidance, and nonworking side and non-nociceptive neurons in the rat's The literature states that demograph- care due to the design of this study.
SJ, Nowlin T. Profile of TMD and bruxer contacts. J Prosthet Dent 1999;82:410-5.
trigeminal subnucleus caudalis (medul- 54.Merikangas KR, Angst J, Isler H. Migraine ic factors, such as income, education, 2. Consistent with previous litera- compared to TMD and nonbruxer patients 31.Kemper JT Jr, Okeson JP. Craniomandibular lary dorsal horn) related to cutaneous and and psychopathology. Ann Gen Psychiatry regarding chief complaint, previous consul- disorders and headaches. J Prosthet Dent deep craniofacial afferent stimulation and general satisfaction and future fears ture, female gender, middle age (30 to tations, modes of therapy, and chronicity. modulation by diffuse noxious inhibitory 55.D'Alessandro R, Benassi G, Lenzi PL. Epi- and hopes are strongly associated 60 years), and muscular pathology, 32.Magnusson T, Carlsson GE. Changes in re- controls. Pain 1990;41:331-45.
demiology of headache in the Republic of with the prevalence of headache.49,51 such as myogenic pain, trigger points, 16.Costa AL, D'Abreu A, Cendes F. Temporo- current headache and mandibular dysfunc- 43.Sessle BJ. Neural mechanisms and path- San Marino. J Neurol Neurosurg Psychiatry mandibular joint internal derangement: tion after various types of dental treatment. ways in craniofacial pain. Can J Neurol Sci Moderate consumption of coffee or combinations have an influence on association with headache, joint effusion, Acta Odontol Scand 1980;38:311-20.
1999;26 Suppl 3:S7-11 56.Pullinger AG, Seligman DA. The degree to and alcohol was less likely to be as- prevalence, frequency, and intensity bruxism, and joint pain. J Contemp Dent 33.Magnusson T, Carlsson GE. A 2½- year 44.Celić R, Jerolimov V, Pandurić J. A study of which attrition characterizes differentiated sociated with headaches. Hagen et of headache.
Pract 2008;9:9-16.
fol ow-up of changes in headache and the influence of occlusal factors and para- patient groups of temporomandibular dis- 17.Wänman A. Craniomandibular disorders mandibular dysfunction after stomatognathic functional habits on the prevalence of signs orders. J Orofac Pain 1993;7:196-208.
al51 reported that high caffeine con- in adolescents. A longitudinal study in an treatment. J Prosthet Dent 1983;49:398-402.
and symptoms of tmd. Int J Prosthodont 57.Keshvad A, WInstanley RB. An appraisal of sumption reduced the risk of frequent urban Swedish population. Swed Dent J 34.Classification and diagnostic criteria for the literature on centric relation. Part III. J headaches in comparison to low caf- Suppl 1987,44:1-61.
headache disorders, cranial neuralgias 45.Nagamatsu-Sakaguchi C, Minakuchi H, Oral Rehabil 2001;28:55-63.
18.Bevilaqua Grossi D, Lipton RB, Bigal ME. and facial pain. Headache Classification Clark GT, Kuboki T. Relationship be- 58.Pullinger AG, Seligman DA. Quantifica- feine consumption, and hinted that 1. Ballegaard V, Thede-Schmidt-Hansen P, Svensson P, Jensen R. Are headache and Temporomandibular disorders and mi- Committee of the International Headache tween the frequency of sleep bruxism and tion and validation of predictive values of caffeine had analgesic properties. In temporomandibular disorders related? A graine chronification. Curr Pain Headache Society. Cephalalgia 1988;8:1-96.
the prevalence of signs and symptoms occlusal variables in temporomandibular the presented data, regression analy- blinded study. Cephalalgia 2008;28:832-41.
Rep 2009;13:314-8.
35.Manzoni GC, Granella F, Sandrini G, Caval- of temporomandibular disorders in an disorders using a multifactorial analysis. J 19.Graff-Radford SB. Temporomandibular lini A, Zanferrari C, Nappi G. Classification adolescent population. Int J Prosthodont Prosthet Dent 2000;83:66-75.
sis showed a protective effect of mild 2. Rasmussen BK. Epidemiology of headache. disorders and headache. Dent Clin North of chronic daily headache by International 59.Arima T, Svensson P, Arendt-Nielsen L. coffee consumption on the etiology 3. Rasmussen BK, Jensen R, Schroll M, Olesen Am 2007;51:129-44.
Headache Society criteria: limits and new 46.Scrivani SJ, Keith DA, Kaban LB. Tem- Experimental grinding in healthy subjects: 20.Cooper BC, Kleinberg I. Relationship of proposals. Cephalalgia 1995;15:37-43.
poromandibular disorders. N Engl J Med a model for postexercise jaw muscle sore- of headache. The authors did not J. Epidemiology of headache in a general population - a prevalence study. J Clin temporomandibular disorders to muscle 36.Hayashi H, Sumino R, Sessle BJ. Functional ness? J Orofac Pain 1999;13:104-14.
identify any association between psy- tension-type headaches and a neuromuscu- organization of trigeminal subnucleus 47.John MT, Hirsch C, Reiber T, Dworkin S. 60.Christensen LV, Tran KT, Mohamed SE. chological impairment and TMD or 4. Bedtsen L, Jensen R. Tension-type head- lar orthosis approach to treatment. Cranio interpolaris: nociceptive and innocuous Translating the research diagnostic criteria Gum chewing and jaw muscle fatigue and afferent inputs, projections to thalamus, for temporomandibular disorders into Ger- pains. J Oral Rehabil 1996;23:424-37.
headache, even though it has previ- ache. Neurol Clin 2009;27:525-35.
5. Bernhardt O, Gesch D, Schwahn C, Mack 21.Schokker RP, Hansson TL, Ansink BJ. Cra- cerebellum, and spinal cord, and descend- man: evaluation of content and process. J ously been described.60 F, Meyer G, John U, et al. Risk factors for niomandibular disorders in headache pa- ing modulation from periaqueductal gray. J Orofac Pain 2006,20:43-52.
Corresponding author: The results of the present study headache, icluding TMD signs and symp- tients. J Craniomandib Disord 1989;3:71-4.
48.Rasmussen BK. Migraine and tension- Dr Matthias Troeltzsch 22.Liljeström MR, Le Bell Y, Anttila P, Aromaa 37.Dessem D, Moritani M, and Ambalavanar type headache in a general population: Maximilianstrasse 5 indicate strong relationships be- toms, and their impact on quality of life. Results of the Study of Health in Pomerania M, Jämsä T, Metsähonkala L, et al. Head- R. Nociceptive Craniofacial Muscle Primary psychosocial factors. Int J Epidemiol tween stomatognathic disorders and (SHIP). Quintessence Int 2005;36 :55-64.
ache children with temporomandibular dis- Afferent Neurons Synapse in Both the Ros- headache. Still, the study has limita- 6. Ciancaglini R, Radaelli G. The relation- orders have several types of pain and other tral and Caudal Brain Stem. J Neurophysiol 49.Waters WE. Migraine: intelligence, social Fax: +49-981-77102 symptoms. Cephalalgia 2005;25:1054-60.
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class, and familiar prevalence. Br Med J tions. The design is cross-sectional, ship between headache and symptoms of temporomandibular disorder in the general 23.Schierz O, John MT, Schroeder E, Lobbezoo 38.Messlinger K. Migraine: where and how determining the state of the patient population. J Dent 2001,29:93-8.
F. Association between anterior tooth wear does the pain originate? Exp Brain Res 50.Abramson JH, Hopp C, Epstein LM. Mi- Copyright 2011 by the Editorial Council for at only one point in time. The con- 7. Wöber-Bingöl C, Wöber C, Karwautz A, and temporomandibular disorder pain graine and non- migrainous headaches. A The Journal of Prosthetic Dentistry. in a German population. J Prosthet Dent 39.Burstein R, Jakubowski M. Unitary hy- community survey in Jerusalem. J Epidemiol current occurrence of headache and Vesely C, Wagner-Ennsgraber C, Am- minger GP, et al. Diagnosis of headache in pothesis for multiple triggers of the pain Community Health 1980;34:188-93.
other problems may be by chance. No childhood and adolescence: a study in 437 24.John MT, Frank H, Lobbezoo F, Drangsholt and strain of migraine. J Comp Neurol systematic process of randomization patients. Cephalalgia 1995;15:13-21.
M, Dette KE. No association between incisal 8. Pergamalian A, Rudy TE, Zaki HS, Greco tooth wear and temporomandibular disor- was applied; thus, there is a risk of CM. The association between wear facets, ders. J Prosthet Dent 2002;87:197-203.
selection bias. In addition, while the bruxism, and severity of facial pain in pa- 25.Seligman DA, Pullinger AG. The role of functional occlusal relationships in significance may be strong for some tients with temporomandibular disorders. J Prosthet Dent 2003;8:194-200.
temporomandibular disorders: a review. J results, the reader should note the 9. Ciancaglini R, Gherlone EF, Radaelli G. The Craniomandib Disord 1991;5:265-79.
extent of the confidence intervals and relationship of bruxism with craniofacial 26.Marzooq AA, Yatabe M, Ai M. What types of occlusal factors play a role in temporo- the number of patients suffering from pain and symptoms from the masticatory system in the adult population. J Oral mandibular disorders? A literature review. J such problems. Due to the limited Med Dent Sci 1999;46:111-6.
number of subjects who displayed 10. Lupoli TA, Lockey RF. Temporomandibular 27.Hagag G, Yoshida K, Miura H. Occlusion, prosthodontic treatment, and temporo- gross occlusal aberrations, statistical dysfunction: an often overlooked cause of chronic headaches. Ann Allergy Asthma mandibular disorders: a review. J Med Dent significance is weak and the chance Sci 2000;47:61-6.
that these observations are coinci- 11.Kraus S. Temporomandibular disorders, dental cannot be ruled out.
head and orofacial pain: cervical spine considerations. Dent Clin North Am The Journal of Prosthetic Dentistry

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Keeping UP on Diabetic Medications and Complications  Apply current clinical practice standards to optimize pharmacologic treatment outcomes and non-pharmacological management strategies for an adult patient with type 2 diabetes.  Recognize patient situations where the utilization of a new or novel pharmacological agent appropriately optimizes type 2 diabetes management.

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HOLY TRINITY CHURCH EICESTER MISSION LINKS AUTUMN 2014 Background, News, MISSION LINKS AUTUMN 2014 3 Here at Holy Trinity we give Our Mission Links are  Andy & Innes Shudall 10% of all giving by the individuals and organisations (TSCF New Zealand) congregation, including Gift that we have chosen to Aid, to people and support through involvement  Roger & Alison Morgan