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Trigeminal nerve injury is one of the causes of chronic orofacial pain. Patients suffering from this condition have a significantly reduced quality of life. The currently available management modalities are associated with limited success. This article reviews some of the common causes and clinical features associated with post-traumatic trigeminal neuropathic pain (PTNP). A cascade of events in the peripheral and central nervous system function is involved in the pathophysiology of pain following nerve injuries. Central and peripheral processes occur in tandem and may often be co-dependent. Due to the complexity of central mechanisms, only peripheral events contributing to the pathophysiology have been reviewed in this article. Future investigations will hopefully help gain insight into trigeminal-specific events in the pathophysiology of the development and maintenance of neuropathic pain secondary to nerve injury and enable the development of new therapeutic modalities.

This cross-sectional study compares prescribing patterns of opioid and nonopioid analgesics and patients’ dental pain outcomes before vs after implementation of an opioid reduction initiative at a single dental clinic.

To investigate the predictive power of depression and anxiety for conditioned pain modulation (CPM) and to examine the relationships of CPM at 40°C and CPM at 47°C with age, disease-related pain, pain duration, and psychosocial factors in burning mouth syndrome (BMS).A total of 22 patients with BMS and 22 healthy female controls participated in this study. Temporal summation was used as the test stimulus for CPM, and subsequent exposure either to a nonpainful (40°C) or a painful (47°C) Peltier thermode was used as the conditioning stimulus. CPM was calculated as the difference in pain perception following the conditioning stimulus. Psychosocial factors were examined using the Profile of Mood States (POMS) and the State-Trait Anxiety Inventory (STAI).State anxiety and tension-anxiety scores were significantly higher for patients with BMS than for control participants. Multiple regression analyses showed that CPM47°C was affected by vigor, fatigue, confusion, and trait anxiety (adjusted RIncreases in trait anxiety reduced the CPM effect. These findings suggest that CPM impairments and increases in trait anxiety are involved in the development of BMS.

Trauma or injury to the dentition and supporting tissues is associated with pain and discomfort, as expected, that may present immediately, shortly afterwards, or within a few days. Pain is an essential response to injury because it allows the organism to develop avoidance behavior to potential threats and helps the organism to avoid usage of the injured organ during the healing process. Not only does external trauma induce pain, but also essential invasive dental procedures such as extractions, dental implant insertions, root canal treatments, and oral surgeries are accompanied by similar post-surgical (post-traumatic) pain. The pain intensity after trauma varies and does not always correlate with the extent of injury. Trauma to the orofacial region or the teeth may also indirectly affect and induce pain in other orofacial structures such as the masticatory muscles, the temporomandibular joint, and even the cervical spine. In most cases, the pain will resolve as soon as healing of the affected tissue occurs or after dental and routine palliative treatment. In a limited number of cases, the pain persists beyond healing and evolves into a chronic pain state. Chronic pain in the orofacial region presents diagnostic and management challenges. Misdiagnosis or delayed diagnosis of the oral chronic pain condition may lead to unnecessary dental treatment. This article will discuss diagnosis and treatment for acute and chronic pain as well as potential mechanisms involved in the undesirable transition from acute to chronic pain.

BACKGROUND: Genetic variation in the catechol-O-methyltransferase (COMT) gene is associated with sensitivity to both acute experimental pain and chronic pain conditions. Four single nucleotide polymorphisms (SNPs) have traditionally been used to infer three common haplotypes designated as low, average and high pain sensitivity and are reported to affect both COMT enzymatic activity and pain sensitivity. One mechanism that may partly explain individual differences in sensitivity to pain is conditioned pain modulation (CPM). We hypothesized that variation in CPM may have a genetic basis. METHODS: We evaluated CPM in 77 healthy pain-free Caucasian subjects by applying repeated mechanical stimuli to the dominant forearm using 26-g von Frey filament as the test stimulus with immersion of the non-dominant hand in hot water as the conditioning stimulus. We assayed COMT SNP genotypes by the TaqMan method using DNA extracted from saliva. RESULTS: SNP rs4680 (val(158)met) was not associated with individual differences in CPM. However, CPM was associated with COMT low pain sensitivity haplotypes under an additive model (p = 0.004) and the effect was independent of gender. CONCLUSIONS: We show that, although four SNPs are used to infer COMT haplotypes, the low pain sensitivity haplotype is determined by SNP rs6269 (located in the 5′ regulatory region of COMT), suggesting that inherited variation in gene expression may underlie individual differences in pain modulation. Analysis of 13 global populations revealed that the COMT low pain sensitivity haplotype varies in frequency from 13% to 44% and showed that two SNPs are sufficient to distinguish all COMT haplotypes in most populations.

It is important for dental care professionals to reliably assess carbon dioxide (CO2) levels and ventilation rates in their offices in the era of frequent infectious disease pandemics. This study was to evaluate CO2 levels in dental operatories and determine the accuracy of using CO2 levels to assess ventilation rate in dental clinics. Mechanical ventilation rate in air change per hour (ACHVENT) was measured with an air velocity sensor and airflow balancing hood. CO2 levels were measured in these rooms to analyze factors that contributed to CO2 accumulation. Ventilation rates were estimated using natural steady-state CO2 levels during dental treatments and experimental CO2 concentration decays by dry ice or mixing baking soda and vinegar. We compared the differences and assessed the correlations between ACHVENT and ventilation rates estimated by the steady-state CO2 model with low (0.3 L/min, ACHSS30) or high (0.46 L/min, ACHSS46) CO2 generation rates, by CO2 decay constants using dry ice (ACHDI) or baking soda (ACHBV), and by time needed to remove 63% of excess CO2 generated by dry ice (ACHDI63%) or baking soda (ACHBV63%). We found that ACHVENT varied from 3.9 to 35.0 in dental operatories. CO2 accumulation occurred in rooms with low ventilation (ACHVENT ≤6) and overcrowding but not in those with higher ventilation. ACHSS30 and ACHSS46 correlated well with ACHVENT ( r = 0.83, P = 0.003), but ACHSS30 was more accurate for rooms with low ACHVENT. Ventilation rates could be reliably estimated using CO2 released from dry ice or baking soda. ACHVENT was highly correlated with ACHDI ( r = 0.99), ACHBV ( r = 0.98), ACHDI63% ( r = 0.98), and ACHBV63% ( r = 0.98). There were no statistically significant differences between ACHVENT and ACHDI63% or ACHBV63%. We conclude that ventilation rates could be conveniently and accurately assessed by observing the changes in CO2 levels after a simple mixing of household baking soda and vinegar in dental settings.

Design Volumetric air flow was measured in a number of dental surgeries to calculate the air change rate per hour (ACHvent). In each surgery, measurements of aerosol removal by ventilation alone, and then with ventilation provided by a high-efficiency particulate air filter (PAC), were completed. The concentrations of aerosol particles of various sizes were recorded at baseline, after an initial period of incense burn, and then after 30 minutes of observation with and without the use of the PAC or ventilation system.Sample selection Ten dental surgeries with differing baseline ventilation rates had the concentrations of 0.3, 0.5 and 1.0 μm aerosol particles measured at 0 minutes, after 5 minutes of incense burn and then after 30 minutes of observation, firstly without the PAC system in operation and then with the PAC system in use.Data analysis For the 0.3 μm particles, velocities of aerosol removal were assessed by analysing the concentration decay constants with ventilation alone and ventilation with the PAC. Aerosol removal velocities were assessed by the time needed to reach 95% and 100% removal of accumulated aerosol particles.Results ACHvent in the ten different surgeries varied from 3-45. The concentration decay constants for the 0.3 μm particles with ventilation alone and ventilation with the PAC were correlated to the mechanical ventilation rate and combined respectively. For rooms with ACHvent of less than 15, accumulated aerosol particles could not be removed by ventilation alone in 30 minutes. The PAC accelerated aerosol removal and reduced aerosol accumulation, and with the use of the PAC in addition to ventilation, accumulated aerosols were removed completely in 4-12 minutes. The PAC was shown to be more beneficial in rooms with poor ventilation and the added effectiveness of the PAC in aerosol removal was inversely correlated with the ACHvent by ventilation.Conclusions Although the air change rate differed considerably among dental surgeries, this study suggests that the addition of the PAC with a HEPA filter significantly increased aerosol removal and lessened aerosol accumulation, particularly in rooms with low ventilation rates.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused much anxiety and confusion in the community and affected the delivery of vital health care services, including dental care. We reviewed current evidence related to the impact of SARS-CoV-2/COVID-19 on dental care and oral health with the aim to help dental professionals better understand the risks of disease transmission in dental settings, strengthen protection against nosocomial infections, and identify areas of COVID-19–related oral health research. When compared with other recent pandemics, COVID-19 is less severe but spreads more easily, causing a significantly higher number of deaths worldwide. Protection of dental patients and staff during COVID-19 is challenging due to the existence of patients who are infectious yet asymptomatic. Dental professionals are ill prepared for the pandemic, as they are not routinely fitted for the N95 respirators now required for preventing contagion during dental treatments. Biological and clinical evidence supports that oral mucosa is an initial site of entry for SARS-CoV-2 and that oral symptoms, including loss of taste/smell and dry mouth, might be early symptoms of COVID-19, presenting before fever, dry cough, fatigue, shortness breath, and other typical symptoms. Oral health researchers may play a more active role in early identification and diagnosis of the disease through deciphering the mechanisms of dry mouth and loss of taste in patients with COVID-19. Rapid testing for infectious diseases in dental offices via saliva samples may be valuable in the early identification of infected patients and in disease progress assessment. Knowledge Transfer Statement: This commentary provides a timely evidence-based overview on the impact of COVID-19 on dental care and oral health and identifies gaps in protection of patients and staff in dental settings. Oral symptoms are prominent before fever and cough occur. Dental professionals may play an important role in early identification and diagnosis of patients with COVID-19.

Objectives The aim of this study was to examine temporal summation (TS) and conditioned pain modulation (CPM) in patients with burning mouth syndrome (BMS) and healthy controls using intra-epidermal electrical stimulation (IES). Materials and methods Twenty-six female patients with BMS and 27 healthy female controls participated in this study. A single stimulus with electrical stimulation followed by a train of 10 successive stimuli was administered to the right chin of participants in both the BMS and control groups. CPM was evaluated with the changes of TS calculated from the difference in numerical pain scale data between these two test stimuli and the following warm (40°C) and hot (47°C) conditioning stimuli applied at the non-dominant hand in both the BMS and control groups. Results TS was present in both the BMS and control groups. CPM in the BMS group was significantly less efficient at the 47°C condition than that in the control group, while no significant difference was observed in the CPM between the BMS and the control groups at the 40°C condition. Conclusion These findings indicate that BMS is associated with a deficit inhibitory CPM and implicate the involvement of the central nervous system in the pathophysiology of BMS.

Aims To evaluate the effect of nonstrenuous aerobic exercise on chronic masticatory myalgia (CMM) patients and healthy controls (HC) by means of mechanical temporal summation (TS) and response to mechanical stimulation (RMS) performed on the dominant forearm. Methods A total of 30 patients diagnosed with CMM and 30 pain-free HCs were first evaluated for maximum number of steps (MNS) on a stepper machine for 1 minute. Additionally, they completed the Generalized Anxiety Disorder (GAD-7), Graded Chronic Pain Scale (GCPS), and Jaw Functional Limitation Scale (JFL) questionnaires. On the second visit, RMS, mechanical TS, exercise-induced hypoalgesia (EIH), blood pressure, pulse pressure, and heart rate were assessed prior to and immediately, 5, 15, and 30 minutes following 5 minutes of stepper exercise at 50% MNS. Results Compared to HCs, CMM patients demonstrated increased mechanical TS and less efficient EIH. Mechanical TS scores were reduced in both groups; however, the HC reduction was more robust and persistent. CMM patients demonstrated a delayed reduction in RMS following exercise in contrast to an immediate reduction in HCs. GAD-7, GCPS, and JFL scores for CMM patients were higher than for HCs and were associated with baseline pain intensity but not with EIH or TS. Conclusion These findings suggest that, compared to HC, CMM patients' pain modulation is both suppressed and has a different effect duration and timing pattern. Further research should explore the mechanisms and clinical relevance of the delayed hypoalgesia and the inhibitory effect on TS induced by nonstrenuous aerobic exercise in CMM patients.

Neuropathic pain encompasses a spectrum of conditions that can arise from a lesion or dysfunction of the central or the peripheral nervous system, and it may develop at variable intervals after nerve injury or inflammation. Nerve injuries arising from surgical procedures commonly occur secondary to the surgical trauma, and in rare instances they are a complication of intubation during general anesthesia or endoscopic procedures. A series of 2 cases of bilateral glossopharyngeal neuropathic pain subsequent to endoscopic procedures is presented with a review of the literature concerning the mechanisms of development of neuropathic pain after these procedures. The purpose of these case reports is to make dentists aware of the occurrence, the mechanisms of nerve injuries, and the treatment of neuropathic pain after endoscopic procedures. In the first case, the patient had relief of pain with a combination therapy of clonazepam 1.0 mg in divided doses twice daily and gabapentin 300 mg in divided doses 3 times daily. In the second case, the patient had significant relief of pain with a monotherapy of gabapentin 1200 mg in divided doses 3 times daily.

We examined the short-term surgical effects of orthognathic surgery on somatosensory function. Observations were made over a short period: 3 months postoperatively. In total, 14 patients and 32 healthy controls participated. Among the 14 patients, one underwent bilateral sagittal split osteotomy alone and 13 underwent bilateral sagittal split osteotomy in combination with a Le Fort I osteotomy. A modified quantitative sensory testing (QST) protocol (the German Research Network on Neuropathic Pain, DFNS) was used to evaluate clinically the skin of the chin for sensory disturbances before surgery and at 1 week, 1 month, and 3 months postoperatively. A visual analog scale and the Japanese Version of the McGill Pain Questionnaire were completed by all participants. Both sides of the mandible showed postoperative functional loss in cold detection threshold, warmth detection threshold, thermal sensory limen, and mechanical detection threshold. All function gradually recovered to baseline conditions at 3 months postoperatively. Cold detection threshold, warmth detection threshold, thermal sensory limen, and mechanical detection threshold appeared to be useful QST parameters for evaluating neurosensory disturbances during the early postoperative period. (J Oral Sci 58, 177-184, 2016).

A standardized battery of quantitative sensory tests developed by the German Research Network on Neuropathic Pain (DFNS) was used to assess the association between somatosensory dysfunction and disease duration in patients with burning mouth syndrome (BMS). The 28 female participants with BMS were classified according to disease duration: ≤ 6 months (subchronic BMS, n = 15) and > 6 months (chronic BMS, n = 13); 29 age- and sex-matched healthy volunteers (control group) were recruited from staff of a dental hospital. The DFNS quantitative sensory testing protocol was applied at the ulnar surface of the right forearm and the tip of the tongue. Values for BMS patients and controls were compared and analyzed. The mechanical detection threshold (MDT) was significantly higher (i.e., loss of sensation) at the tongue tip in the chronic BMS group than in the control group (p = 0.011), whereas mechanical pain sensitivity (MPS) at the forearm was significantly higher (i.e., gain of sensation) in the chronic BMS group than in the control group (Z score = − 2.13 and 1.99, respectively). Multivariate analyses revealed that BMS patients could be discriminated from controls by using pressure pain threshold at the tongue (79.3%) (in the subchronic BMS group) and by MDT and MPS at the tongue tip and MPS at the forearm (96.6 and 89.7%, respectively) (in the chronic BMS group). In BMS patients with long disease duration, MDT showed loss of sensation. Increased MPS suggests that a neuropathic mechanism in the peripheral and central nervous systems is involved in BMS development.

Despite the advancement of early childhood caries (ECC) prediction and treatment, ECC remains a significant public health burden in need of more effective preventive strategies. Pregnancy is an ideal period to promote ECC prevention given the profound influence of maternal oral health and behaviors on children’s oral health. However, studies have shown debatable results with respect to the effectiveness of ECC prevention by means of prenatal intervention. Therefore, this study systematically reviewed the scientific evidence relating to the association between prenatal oral health care, ECC incidence, and Streptococcus mutans carriage in children. Five studies (3 randomized control trials, 1 prospective cohort study, and 1 nested case-control study) were included for qualitative assessment. Tested prenatal oral health care included providing fluoride supplements, oral examinations/cleanings, oral health education, dental treatment referrals, and xylitol gum chewing. Four studies that assessed ECC incidence reduction were included in meta-analysis using an unconditional generalized linear mixed effects model with random study effects and age as a covariate. The estimated odds ratio and 95% confidence intervals suggested a protective effect of prenatal oral health care against ECC onset before 4 years of age: 0.12 (0.02, 0.77) at 1 year of age, 0.18 (0.05, 0.63) at 2 years of age, 0.25 (0.09, 0.64) at 3 years of age, and 0.35 (0.12, 1.00) at 4 years of age. Children’s S. mutans carriage was also significantly reduced in the intervention group. Future studies should consider testing strategies that restore an expectant mother’s oral health to a disease-free state during pregnancy.

Orofacial pain has multifactorial causes and is often a diagnostic challenge. Misdiagnosis can result in morbidity or mortality due to misdirected and inappropriate treatment. A delay of necessary treatment, in cases of ominous illnesses, may result in its perpetuation or progression. The authors present a case report that illustrates these possibilities.This case report describes a 36-year-old woman with the chief symptom of painless, limited mandibular movement. She also reported restricted movement of the left eye. She was previously diagnosed and treated for a traumatic right inferior alveolar nerve neuropathy, migraine, myofascial pain, and bilateral temporomandibular joint disk displacement with minimal benefit. Eventually she sought an orofacial pain evaluation, presuming her problems were related to a temporomandibular disorder. A complete history and comprehensive clinical evaluation including a cranial nerve screening evaluation, intraoral and extraoral examinations, an evaluation of the masticatory system, and dental radiographs were performed. The cranial nerve screening examination found painful, restricted eye movements. Magnetic resonance revealed a large, soft tissue mass in the inferolateral wall of the left orbit with soft tissue components in the infratemporal fossa and pterygoid space, involving the lateral pterygoid muscle and insertion of the temporalis muscle. The patient was referred to appropriate medical specialties and the diagnosis of orbital pseudotumor was confirmed and the patient was treated appropriately.The case emphasizes the importance of a comprehensive evaluation of a patient with preexisting orofacial pain when new symptoms arise or if there is a change in existing symptoms.

Patients suffering from persistent pain after endodontic treatment have less efficient pain modulation system compared with healthy controls., Persistent pain may follow nerve injuries associated with invasive therapeutic interventions. About 3% to 7% of the patients remain with chronic pain after endodontic treatment, and these are described as suffering from painful posttraumatic trigeminal neuropathy (PTTN). Unfortunately, we are unable to identify which patients undergoing such procedures are at increased risk of developing PTTN. Recent findings suggest that impaired endogenous analgesia may be associated with the development of postsurgical chronic pain. We hypothesized that patients with PTTN display pronociceptive pain modulation, in line with other chronic pain disorders. Dynamic (conditioned pain modulation, temporal summation) and static (response to mechanical and cold stimulation) psychophysical tests were performed intraorally and in the forearm of 27 patients with PTTN and 27 sex- and age-matched controls. The dynamic sensory testing demonstrated less efficient conditioned pain modulation, suggesting reduced function of the inhibitory endogenous pain-modulatory system, in patients with PTTN, mainly in those suffering from the condition for more than a year. The static sensory testing of patients with PTTN demonstrated forearm hyperalgesia to mechanical stimulation mainly in patients suffering from the condition for less than a year and prolonged painful sensation after intraoral cold stimulus mainly in patients suffering from the condition for more than a year. These findings suggest that PTTN is associated more with the inhibitory rather than the facilitatory arm of pain modulation and that the central nervous system has a role in PTTN pathophysiology, possibly in a time-dependent fashion.

BACKGROUND Although inflammation can alter cytokines release and nerve function, it is not yet fully established if orthodontic-induced inflammation can cause significant extraoral trigeminal somatosensory alterations and release of inflammatory chemical mediators. OBJECTIVE The primary aim of this study was to investigate the impact of orthodontic separator and short-term fixed orthodontic appliance on the extraoral trigeminal somatosensory function and concentrations of cytokines in the gingival crevicular fluid (GCF). METHODS Twenty-two female patients were evaluated as follow: baseline, 24 hour-after elastomeric separator (-aES), 24 hour- and 1 month-after bonding brackets (-aBB) at both arches. The outcome variables were as follows: self-reported pain (Visual Analog Scale), QSTs (current perception threshold-CPT, cold detection threshold-CDT, warm detection threshold-WDT, mechanical detection threshold-MDT, mechanical suprathreshold-MST and wind-up ratio-WUR. All QSTs were performed at infra-orbital and mental nerve entry zone at patient`s dominant side. In addition, GCF samples in order to assess cytokines profile (IL-1β,IL-8,IL-6 and TNF-α) were collected. ANOVA and Tukey's post hoc analyses were performed (a = 5%). RESULTS Patients reported higher pain intensity 24 hour-aBB compared to baseline and 24 hour-aES (P

This article discusses neuropathic pain of traumatic origin affecting the trigeminal nerve. This syndrome has been termed painful traumatic trigeminal neuropathy by the International Headache Society and replaces atypical odontalgia, deafferentation pain, traumatic neuropathy, and phantom toothache. The discussion emphasizes the diagnosis and the early and late management of injuries to the trigeminal nerve and subsequent painful conditions.

Purpose We performed a retrospective study of lingual nerve injury assessment comparing the techniques of current perception threshold testing versus clinical sensory testing. Patients and Methods We designed and implemented a cross-sectional study and enrolled a patient sample with lingual nerve injuries presenting for treatment to the principal investigator. The predictor variables were clinical sensory testing modalities (ie, temperature, nocioception, vibration, 2-point discrimination, brush stroke, and von Frey monofilament perception). The primary outcome variable was the electrical current perception thresholds of the tongue dorsum (neurometer measurements at 5, 250, and 2,000 Hz). Comparisons were established with the ipsilateral affected and contralateral unaffected lingual nerve distributions. The associations between the clinical sensory testing and current perception threshold measurements were assessed using correlation coefficients, with the level of statistical significance set at P Results A total of 40 patients (13 males and 27 females) were included in the present study. The average age of these patients was 34 years (range 13 to 66). Significant correlations were observed between the electrical stimulation thresholds at 2,000 Hz and the 2-point discrimination, reaction to brushing, reaction to vibration, and von Frey fiber thresholds, between the electrical stimulation thresholds at 250 Hz to the nociceptive and thermal thresholds, and between the electrical stimulation thresholds at 5 Hz to thermal stimuli. Conclusions The significant correlations observed in the present study indicate that current perception threshold can be a complementary or alternative tool in the assessment and evaluation of lingual nerve injuries.

Objective The aim of this study was to evaluate patients suffering from burning mouth syndrome (BMS) and control subjects by means of sensory testing and fungiform papillae count. Study design The left and right anterior two-thirds of the tongue of of 25 BMS subjects and 20 healthy control subjects were evaluated for electric taste and electric detection threshold. The number of fungiform papillae/cm 2 was evaluated by using close-up digital photography. Results The electric taste/tingling detection threshold ratio was significantly higher in BMS compared with control subjects ( P = .041). No difference was found between the number of fungiform papillae/cm 2 in the BMS compared with the control subjects ( P = .277). Patients suffering from BMS for a prolonged period of time presented with a significantly elevated electric taste/tingling detection threshold ratio ( P = .031). Conclusions BMS may be a neurodegenerative process with chorda tympani nerve hypofuction potentially playing a role in the pathophysiology of this disorder.

Objective The aim of this study was to examine atypical odontalgia (AO) patients with extraoral quantitative sensory testing (EQST) and an intraoral mucosal cold test. Study design Twenty-one subjects with AO and 18 control subjects underwent EQST for electrical and thermal pain and detection thresholds. Cold was applied to painful mucosal areas in AO patients and randomly in control subjects. Results Electrical pain thresholds were higher in AO patients than in control subjects in the same dermatome affected by the pain (P = .03), but no significant differences were observed in electrical detection thresholds and heat pain and detection thresholds at other sites. Cold application was painful in control and AO subjects, but duration of pain sensation was significantly longer in AO patients (P = .019 in contralateral side; P = .029 in affected side). Conclusions The finding of extended painful aftersensation following cold application in AO patients supports the involvement of central mechanisms. The cold test is clinically easy to apply and of clinically significant value.

(1) To investigate the development of hypoesthesia from soon after the whiplash injury to 6 months postinjury and (2) to determine differences in detection thresholds between those with initial features of poor recovery and those without these signs.Fifty-two participants with acute whiplash-associated disorders (WAD) (1 mo) were classified as either "high-risk" (n=17; Neck Disability Index30; sensory hypersensitivity) or "low risk" (n=35; without these signs). Detection thresholds to electrical, thermal, and vibration stimuli and psychological distress were prospectively measured within 1 month of injury and then 3 and 6 months postinjury. Detection thresholds were also measured in the 38 controls.Both WAD groups showed hypoesthesia (vibration, electrical, and cold) at 1 month postinjury. Vibration and electrocutaneous hypoesthesia persisted to 3 and 6 months only in the high-risk WAD group. Heat detection thresholds were not different between the groups at 1 month postinjury but were elevated in the high-risk group at 3 and 6 months. Both WAD groups were distressed at 1 month but this decreased by 3 months in the low-risk group. The differences in the Impact of Event Scale did not impact on any of the sensory measures.Sensory hypoesthesia is a feature of acute WAD but persists only in those at higher risk of poor recovery. These findings suggest the involvement of the central inhibitory mechanisms that may be sustained by ongoing nociception.

Hypersensitivity to a variety of stimuli has been shown in whiplash associated disorders and may be indicative of peripheral nerve involvement. This cross-sectional study utilised Quantitative sensory testing (QST) including vibration, thermal, electrical detection thresholds as an indirect measure of primary afferents that mediate innocuous and painful sensation. Pain thresholds and psychological distress (SCL-90-R) were also measured. Thirty-one subjects with chronic whiplash (3 months, NDI: 49+/-17) and 31 controls participated. The whiplash group demonstrated elevated vibration, heat and electrical detection thresholds at most hand sites compared to controls (p0.05). Electrical detection thresholds in the lower limb were no different from controls (p=0.83). Mechanical and cold pain thresholds were lower in the whiplash group (p0.05) with no group difference in heat pain thresholds (p0.1). SCL-90 scores were higher in the whiplash group but did not impact on any of the sensory measures. A combination of pain threshold and detection measures best predicted the whiplash group. Sensory hypoaesthesia and hypersensitivity co-exist in the chronic whiplash condition. These findings may indicate peripheral afferent nerve fibre involvement but could be a further manifestation of disordered central pain processing.

The objective of this study was to evaluate the effect of topical medications as a single treatment or in combination with systemic medications in the treatment of orofacial neuropathic pain conditions.A retrospective chart review of 39 patients treated for orofacial neuropathic pain at the Orofacial Pain Clinic in the New Jersey Dental School was performed. In line with the treatment selection, the subjects were divided into 3 groups: topical medications only (n = 12), systemic medications only (n = 10), and a combination of both (n = 17).The starting pain level as expressed in pain Visual Analog Scale for the 3 groups was significantly different. The combined treatment group baseline pain level (7.5 +/- 0.403 SEM; P = .0015) and the systemic treatment only group pain level (8.6 +/- 0.611 SEM; P = .0375) was significantly elevated compared to the topical only group (6.1 +/- 0.716 SEM; P = .1057). Following treatment, pain level was significantly reduced in all 3 groups. The combined group had the highest pain relief (52.0 +/- 6.676 SEM % reduction; P.0001) followed by the systemic-only group (40.6 +/- 9.727 SEM % reduction; P = .0029) and the topicals-only group (40.9 +/- 10.775 SEM% reduction; P = .0048). The time taken for the topical treatment only to act was significantly shorter (3 weeks +/- 0.479 SEM; P = .0015) when compared with the systemic-only (4 weeks +/- 0.772 SEM; P = .3629) and the combined group (5.5 weeks +/- 0.912 SEM; P = .1738).Topical medication as single treatment or in combination with systemic medications can reduce orofacial neuropathic pain severity. Further prospective research should be performed to validate this treatment option.

The mechanisms involved, and possible treatment targets, in orofacial pain due to cancer are poorly understood. The aim of the first of this two-part series is to review the involved pathophysiological mechanisms and explore their possible roles in the orofacial region. However, there is a lack of relevant research in the trigeminal region, and we have therefore applied data accumulated from experiments on cancer pain mechanisms in rodent spinal models. In the second part, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. In the present article, we provide a brief outline of trigeminal functional neuro-anatomy and pain-modulatory pathways. Tissue destruction by invasive tumors (or metastases) induces inflammation and nerve damage, with attendant acute pain. In some cases, chronic pain, involving inflammatory and neuropathic mechanisms, may ensue. Distant, painful effects of tumors include paraneoplastic neuropathic syndromes and effects secondary to the release of factors by the tumor (growth factors, cytokines, and enzymes). Additionally, pain is frequent in cancer management protocols (surgery, chemotherapy, and radiotherapy). Understanding the mechanisms involved in cancer-related orofacial pain will enhance patient management.

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

To review the current literature, and to evaluate the occurrence, severity, and duration of tooth sensitivity during and after vital tooth bleaching as well as to identify possible sources and risk factors of bleaching sensitivity (BS). The inclusive analysis should allow the clinician to get an overview about today's evidence based results concerning BS.The search included Cochrane Central Register of Controlled Trials, Ebsco, Embase, PubMed, and Scopus from February 1991 to February 2015. Studies published in English and German were considered.Randomized controlled trials including placebo or control groups, with statistical analysis of BS interventions, and with a study sample size of at least 30 participants at baseline were selected.Screening of titles and abstracts, data extraction, and quality assessment of full texts were undertaken.A total of 136 articles were identified, with 18 papers meeting the inclusion criteria and presenting data that could be used in the analysis. Included trials provided some details on occurrence, severity, or duration of BS, but papers did not focus solely on BS. The majority of the studies were judged to be at a high risk of bias according to their study design. Investigation methods and outcomes concerning severity of BS and duration varied significantly. Evidence-based explanations for BS could not be found.BS still remains an unsolved phenomenon that needs further follow-up with high-quality studies following the well-accepted CONSORT guidelines.

Objective. To document the neurosensory changes in the infraorbital nerve following zygomatic fractures managed in various ways. Study design. Twenty-five patients were included in the study. Neurosensory function was assessed with calibrated nylon monofilaments, electrical stimulation, heat detection thresholds and response to pin prick in the infraorbital, supraorbital, and mental nerve regions. Patients were seen immediately post-trauma, then 1 and 6 months following surgery. Results. Nine fractures were caused by traffic accidents (TAs), 8 by falls, and 8 by a local blow in a physical dispute. The fractures consisted of 15 displaced and 10 minimally or nondisplaced zygomatic complex fractures, and were left surgically untreated in 7 cases (None group), reduced but not fixed in 8 cases (Reduction group), and fixed with plates in 10 cases (Plates group). Plates were employed significantly more often in displaced fractures (chi-squared P = .0006). At 6 months significantly improved infraorbital nerve function was found in the Plate and None groups relative to the Reduction group (ANOVA P = .006). Only 1 case of chronic neuropathic pain was found. Conclusions. This study concurs with previous studies in finding that plate fixation allows for significantly better restoration of infraorbital nerve function. Chronic neuropathic pain following zygomatic fractures is rare. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:657-65) Zygomatico-orbital fractures are one of the most common facial injuries 1-3 and have been estimated to occur in 10.4 per 100,000 inhabitants. 4 In most cases fracture lines involve the infraorbital (IO) foramen, canal, or fissure. Therefore, fractures of the zygomatic complex are characterized by sensory neuropathy (specifically hypoesthesia) in the area of innervation of the IO nerve both as a presenting symptom and as a postoperative complication. 5-7 Some studies 5,8 have

Objective. Juvenile recurrent parotitis (JRP) is a nonobstructive, nonsuppurative parotid inflammation in young children. Causative factors, such as local autoimmune manifestation, allergy, infection, and genetic inheritance, have been suggested, but none of them has been proved to date. Until now, treatment of JRP was divided into conservative observation and antibiotic treatment, and no preventive therapy was available. Methods. Twenty-six cases symptomatic JRP in children were diagnosed and treated with a combined endoscopic approach. Sialography and sialoendoscopy were performed bilaterally in all children. The treatment modality was composed of lavage, ductal dilation, and hydrocortisone injection. Results. Sialography showed multiple sialectasis in the affected gland and in the contralateral one as well. Dilations and strictures were noticed in the main duct, and kinks could be identified in 31% of the glands. The main endoscopic finding was a white appearance of the ductal layer without the healthy blood vessel coverage. Recurrence of the symptoms occurred in only 2 (8%) children. Conclusions. The endoscopic technique provides the possibility of a correct diagnosis and treatment. In this article, we present a new treatment modality of irrigation and dilation under direct vision by endoscopically guided miniature surgical instruments.

Heat and electrical detection thresholds were assessed in 72 patients suffering from painful temporomandibular disorder. Employing widely accepted criteria, 44 patients were classified as suffering from temporomandibular joint (TMJ) arthralgia (i.e. pain originating from the TMJ) and 28 from myalgia (i.e. pain originating from the muscles of mastication). Electrical stimulation was employed to assess thresholds in large myelinated nerve fibers (Abeta) and heat application to assess thresholds in unmyelinated nerve fibers (C). The sensory tests were performed bilaterally in three trigeminal nerve sites: the auriculotemporal nerve territory (AUT), buccal nerve territory (BUC) and the mental nerve territory (MNT). In addition, 22 healthy asymptomatic controls were examined. A subset of ten arthralgia patients underwent arthrocentesis and electrical detection thresholds were additionally assessed following the procedure. Electrical detection threshold ratios were calculated by dividing the affected side by the control side, thus reduced ratios indicate hypersensitivity of the affected side. In control patients, ratios obtained at all sites did not vary significantly from the expected value of 'one' (mean with 95% confidence intervals; AUT, 1:0.95-1.06; BUC, 1.01:0.93-1.11; MNT, 0.97:0.88-1.05, all areas one sample analysis P>0.05). In arthralgia patients mean ratios (+/-SEM) obtained for the AUT territory (0.63+/-0.03) were significantly lower compared to ratios for the MNT (1.02+/-0.03) and BUC (0.96+/-0.04) territories (repeated measures analysis of variance (RANOVA), P

Objective. We sought to assess the efficacy of sialoendoscopic mechanical retrieval techniques for the treatment of obstructive salivary gland disease. This study documents the authors' long-term experience with mechanical retrieval techniques, the long-term results of the procedures, the technical issues, the techniques that have been used, and the advantages and limitations of these modalities. Study design. Mechanical endoscopic techniques were used in a large referral center from 1993 to 2001 to treat 217 salivary glands for salivary gland sialolithiasis. Results. We found that 189 of the 217 glands with salivary gland sialolithiasis became completely symptom- and stone-free, both endoscopically and by radiographs (overall success rate, 87%). In the submandibular gland group specifically, the success rate was higher, 89%. In the parotid group, it was 83%. Follow-up was continued for 40 months after treatment. No severe complications were noted. The endoscope used was the third-generation Sialoendoscope. Conclusion. The endoscopic mechanical retrieval of sialoliths is both safe and efficacious. This is an excellent method for the complete and certain removal of sialoliths, with minimal damage to the surrounding tissue. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:396-402)

Purpose: This article describes the use of combined endoscopic and ultrasound approach to locate and to extract impacted parotid stones, which cannot be retrieved by intraoral approach alone. Patients and Methods: A total of 12 parotid glands from 7 women and 5 men (age range, 35 to 62 years) with parotid sialoliths were treated with the combined method. Eleven of 12 of the procedures were performed under local anesthesia in an outpatient clinic. The identification of the calculi was done in 5 patients with 1.3-mm sialoendoscope (Nahlieli Sialoendoscope; Karl Storz, Tuttlingen, Germany) in 6 patients with the aid of high-resolution ultrasound, and in 1 patient the location was combined endoscopy and ultrasound. The removal of the calculi was performed extraorally via minimal incision. The indications for the combined approach were 1) calculus in the posterior third of the Stensen's duct with too narrow duct anterior to it, 2) obstruction of the posterior or middle third of the Stensen's ducts leading to the calculus, 3) large (>5-mm) stones in the middle or posterior part of the duct that cannot be dilated for intraductal removal, and 4) intraparenchymal stones. Results: Of the 12 patients, 9 had complete removal (75%); in 1 case with 3 sialoliths, we removed 2 and the gland remained asymptomatic. In 7 cases, the glands returned to function, 3 glands became atrophic with no function, but the gland remained asymptomatic. The aesthetic results were satisfactory in all cases, no major complications were noted. Conclusions: Combined endoscopic ultrasound approach is another minimal invasive technique for identification and removal of impacted parotid sialolithiasis. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1418-1423, 2002

Objectives: Research suggests that varied etiologic factors areresponsible for burning mouth syndrome (BMS). We examined therole of immune and endocrine function in the pathology of BMS.Methods: We conducted a case-control study to evaluate immune(lymphocyte subpopulations) and endocrine (hypothalamus-pitui-tary-adrenal axis and sympathetic-adrenomedullary system) func-tion in 47 female BMS patients and 47 age-matched female controlspresenting at an university clinic. Psychological state was assessedwith the Zung Self-Rating Depression Scale and Taylor ManifestAnxiety Scale.Results: BMS patients were significantly more anxious than con-trols (P=0.011). Plasma adrenaline level was significantly lower(P=0.020) in BMS patients than in controls, and linear regressionanalysis of all patients combined revealed that depression level wassignificantly positively associated with plasma noradrenaline andcortisol levels (P=0.002 and 0.001, respectively). However, ascompared with controls, BMS patients had a significantly lowerCD8(+) cell count (P

Purpose: This article describes the use of sialoendoscopy for diagnosis and treatment of strictures and kinks in the major salivary glands ducts. Patients and Methods: Thirty-four salivary glands with obstruction were diagnosed as having ductal kinks or strictures. Strictures were diagnosed by sialography and sialoendoscopy, kinks were diagnosed mainly by sialography, whereas endoscopy was used to rule out other pathology and to locate the kink. There were strictures in 25 salivary glands (14 male and 11 females; aged 25 to 60 years), 14 in the parotid and 11 in the submandibular gland, and kinks in 9 salivary glands (5 males 4 females; aged 40 to 55 years). Seven kinks were found in the submandibular gland and 2 in the parotid. Treatment of strictures was performed by dilatation procedures with saline under pressure, balloon techniques, and forced manipulation. After these procedures, a polyethylene stent was inserted for 2 weeks. Kinks were treated by advancement ductoplasty and balloon contouring to overcome the acute angle. Results: Twenty of 25 cases of stricture became completely asymptomatic in a follow-up of 8 to 36 months after treatment. In 4 cases, further revisional dilatation was needed, and in 1 case treatment failed and the gland had to be removed. All 9 cases of kinks became completely asymptomatic in a follow-up of 6 to 24 months after treatment. Conclusion: Strictures and kinks should be considered when salivary gland obstruction is present without sialolithiasis. © 2001 American Association of Oral and Maxillofacial Surgeons

In a 2-armed, double-blind, randomized clinical study, the efficacy in the treatment of recurrent herpes labialis of 5% acyclovir in a novel liposomal carrier (ethosome) was evaluated in comparison with that of a commercial 5% acyclovir cream (Zovirax cream) and that of a drug-free vehicle. Data were based on 61 herpetic episodes in 40 subjects. In a crossover arm in which the 2 active preparations were compared, the time to crusting of lesions was significantly shorter (P < .025) with the ethosomal acyclovir (1.8 days) than with the cream (3.5 days). Time to loss of crust was also significantly shorter (4.2 vs 5.9 days; P < .05). In a parallel arm in which all 3 preparations were compared, the time to crusting with the ethosomal acyclovir (1.6 days) was significantly shorter than the time with the acyclovir cream (4.3 days; P < .02) and the time with the drug-free vehicle (4.8 days; P < .005); in this arm, the shorter time to loss of crust for the ethosome (3.5 days), in comparison with the times for the cream (6.4 days) and the drug-free vehicle (6.1 days), did not reach statistical significance. Approximately 30% of all episodes treated with the ethosome were clinically abortive; this compared with 10% of those treated with the cream or the drug-free vehicle. No adverse effects were reported, other than minor burning sensations at the application site that lasted a few seconds after application and were evenly distributed between the investigated preparations. This pilot study suggests the improved clinical efficacy of the new liposomal preparation in comparison with Zovirax cream in the treatment of recurrent herpes labialis.

Post-injury inflammation activates nociceptive systems and recruits normally non-nociceptive afferents into a pain processing role. During inflammation, Abeta low threshold mechanoreceptor afferents that usually mediate tactile sensation acquire properties of nociceptors, allowing them to participate in post-injury spontaneous pain and evoked abnormalities such as tenderness and pain to light touch. This study assessed the sensory consequences of post-injury inflammation following extraction of a single, lower third molar tooth. Extensive bilateral evaluations were performed in the territory of nerves assumed to be exposed to both inflammation and mechanical trauma, inflammation alone, or only the central consequences of peripheral inflammation. Testing at the distal termination of nerves assumed to be exposed to local inflammation (mental and lingual nerve territory) revealed decreased detection thresholds (P0.05) to electrical stimulation and to mechanical stimulation by sensitive, disposable filaments developed and validated for this application. Testing at sites of assumed inflammation and mechanical trauma (mental nerve territory) showed reduced pain thresholds to electrical stimulation. Thermal detection and pain thresholds were not altered at any location in patients, and no effects were observed in control subjects receiving only local anesthetic injections. These results in humans are consistent with recent experimental evidence that inflammatory processes alter the central consequence of activity in large-diameter Abeta touch primary afferents evoked under natural conditions by gentle mechanical stimulation. These effects result in hyperesthesia, increased sensitivity to light touch, and mechanical allodynia, pain evoked by normally innocuous stimulation of Abeta primary afferents.

Piercing has become so popular during the last 20 to 30 years that many physicians are now treating patients with piercings and dealing with its side effects. We present 3 cases that illustrate the complications of tongue piercing (ie, infection, bleeding, and embedded ornaments). We describe the methods for inserting the ornaments to illustrate the possible adverse effects. Treatment recommendations and their application to those 3 patients are described.