Applicability of non-pharmacological strategies for pain relief in parturient: integrative review

MORAES, Maísa Suares Teixeira; ROLIM, Lariane Thays Albuquerque; ENDERS, Bertha Cruz; FARIAS, Glaucea Maciel de; DAVIM, Rejane Marie Barbosa. Applicability of non-pharmacological strategies for pain relief in parturient: integrative review. Revista de Enfermagem UFPE on line, v.4, n.especial, p.131-136, May/June 2010. Disponivel em:< http://www.ufpe.br/revistaenfermagem/index.php/revista/>.

Construção e validação de instrumento simplificado para diagnóstico de disfunção temporomandibular em pacientes adultos

As disfunções temporomandibulares (DTM) representam a maior causa de dor não dentária da região orofacial. Dada sua alta prevalência na população em geral e a existência de inúmeros instrumentos diagnósticos não padronizados, buscou-se elaborar e validar um questionário simples, de acessibilidade ampla e aplicação prática, com vistas a contribuir para o diagnóstico e o estudo epidemiológico das mesmas. A estratégia utilizada na montagem do instrumento foi estabelecida com base na avaliação criteriosa de questionários já existentes na literatura, validação de expertos na área de DTM, validação fatorial, de face (na primeira fase do estudo) e, frente ao padrão ouro (RDC/TMD), na segunda fase do estudo. Na primeira fase, participaram 160 indivíduos. A consistência interna resultou num Coeficiente Alfa de Cronbach de 0,752 para o questionário com sete itens; enquanto que para o questionário com cinco itens, este resultado foi de 0,694, não sendo o mesmo, considerado baixo por avaliar apenas cinco questões e ainda, em razão do tema central da pesquisa ser bastante subjetivo. A análise fatorial confirmatória apontou para uma variância total dos fatores extraídos do questionário com sete itens, de 58,2 % e do questionário com cinco itens de 70,04%. Portanto, o questionário com cinco questões, apresentou resultados estatísticos superiores ao de sete questões. Na validação frente ao padrão ouro (RDC/TMD), foram avaliados 99 indivíduos tendo sido testados os dois questionários, com sete e com cinco questões. Na estrutura com sete questões, ao se categorizar as mesmas por totais de pontos obtidos, em quatro condições, obteve-se o melhor resultado quando se considerou com DTM a faixa entre 10 e 21 pontos, sendo 85,1% positivos também no RDC/TMD, com acurácia de 90,1% e Kappa 0,817. Nesta condição, a sensibilidade encontrada foi de 95% (IC 95%, 91 a 99), especificidade de 87% (IC 95%, 81 a 93), VPP 85%, VPN 96%, LR+ 7,3 e LR- 17,4. Quando os dados foram avaliados para o questionário com cinco questões (QST/DTM), pode-se observar que o melhor ponto de corte foi quando se considerou como portadores de DTM, os indivíduos na faixa entre 7 e 15 pontos, com acurácia de 85,8% e Kappa 0,817. Nesta condição, a sensibilidade foi 88% (IC 95%, 81,6 a 94,4), especificidade 84% (IC 95%, 76,8 a 91,2), VPP 80%, VPN 90,5%, LR+ 5,5 e LR- 7,0. A simplicidade do presente questionário (QST/DTM) com apenas cinco questões, possibilita seu uso como elemento de triagem inicial na área da dor orofacial em disfunção temporomandibular, com boa compreensibilidade, confiabilidade, reprodutibilidade e possibilidade de aplicação em pesquisas epidemiológicas. Concluiu-se que o questionário aqui validado, permite sua aplicação de forma simples tanto por profissionais e pesquisadores da Odontologia como de outras áreas da saúde

Qualidade de vida, eficiência mastigatória e presença de disfunção temporomandibular em usuários de prótese parcial removível com arco dental curto inferior

Even nowadays there is in Brasil a large number of edentulous and a precarious financial condition of most of the population. In addition, World Health Organization aims for oral health, which consists on the maintenance of a natural dentition, functional and aesthetic composed of at least 20 teeth, without need of prosthetic intervention throughout life. From this and considering the lack of researches about the permanence of edentulous spaces in the oral cavity, and also avoiding overtreatment, this research has been proposed. Thus, the aim was to evaluate the effect of different lengths of the shortened lower dental arch in the presence or absence of a removable partial denture (RPD) on masticatory function, quality of life and occurrence of temporomandibular dysfunction. To achieve this goal, we compared the masticatory efficiency (colorimetric test), the oral comfort through the analysis of the impact of oral health in quality of life (OHIP-14), the presence of temporomandibular dysfunction (RDC/TMD) and the general quality of life (WHOQOL) of patients with shortened dental arches (SDA) (n=60), which is an arch with a reduction of teeth starting posteriorly, and patients with complete dental arch (Complete DA) (n = 34). The group of patients whit SDA was divided among PPR wears (PPD + SDA) (n = 17) and non-wears (n = 43). The population of this study consisted on patients who received or looked for treatment at the clinics of the Department of Dentistry of UFRN, from clinical analysis and records. The sample was chosen by convenience. For statistical analysis, it was a database in SPSS 17.0, followed by descriptive analysis with frequencies, absolute values, tests of central tendency and variability. The statistical tests used were chi-squared and analysis of variance as well as Tukey s post test, when applicable, all with a 95% confidence level. The results shown a prevalence of TMD of 47,1% among patients using PRP and 69,8% among those who didn t, but this result wasn t statistically significant. The mean of the results of masticatory efficiency, WHOQOL and OHIP didn t show association to the presence or absence of PPR and to the lower number of occlusal units of the patients (0, 1, 2 or more occlusal). The association only occurred among the different groups of SDA and the patients with complete dental arch. Taking into account the results, it could be observed that studied patients with low posterior support using lower PRP didn t have better masticatory efficiency, general quality of life, less impacts of their oral conditions in quality of life or not even less temporomandibular dysfunction or better masticatory efficiency when compared to those who didn t use the prosthesis

Putative antinociceptive action of nitric oxide in the caudal part of the spinal trigeminal nucleus during chronic carrageenan-induced arthritis in the rat temporomandibular joint

In order to investigate a putative role for nitric oxide (NO) in the central nociceptive processing following carrageenan-induced arthritis in the rat temporomandibular joint (TMJ), we analyzed the immunoreactivity, gene expression and activity of nitric oxide synthases (NOS) in the caudal part of the spinal trigeminal nucleus (Sp5C) during the acute (24 h), chronic (15 days) and chronic-active (14 days-24 h) arthritis. In addition, evaluation of head-withdrawal threshold was carried out in all phases of arthritis under chronic inhibition of nNOS with the selective inhibitor 7-nitroindazole (7-NI). Neurons with nNOS-like immunoreactivity (nNOS-LI) were concentrated mainly in the lamina II of the Sp5C, showing no significant statistical difference during arthritis. Only a discrete percentage of nNOS-LI neurons expressed Fos immunoreactivity. The mRNA expression for both nNOS and endothelial nitric oxide synthases (eNOS) presented no noticeable differences among the groups. No expression of inducible nitric oxide synthase (iNOS) was detected in the Sp5C by either immunohistochemistry or reverse-transcription polymerase chain reaction (RTPCR). Ca(2+)-dependent NOS activity in the ipsilateral Sp5C was significantly higher (108.3 +/- 49.2%; P<0.01) in animals during the chronic arthritis. Interestingly, this increased activity was completely abolished 24 h later, in the chronic-active arthritis. Finally, head-withdrawal threshold decreased significantly in the chronic arthritis in animals under 7-NI chronic inhibition. In conclusion, nNOS immunoreactivity and mRNA expression are stable in the Sp5C during TMJ arthritis evolution, but its activity significantly increases in the chronic-phases supporting an antinociceptive role of the nNOS as evidenced by pain threshold experiment. (C) 2009 Elsevier B.V. All rights reserved.

Dental Practice and Musculoskeletal Disorders Association: A Look at the Evidence

Disorders localized to the musculoskeletal system are a common problem among dental personnel. This study has the aim of surveying epidemiological studies reporting positive associations between dental practice and musculoskeletal disorders (MSKDs). The focus was to evaluate the size of reported risk increase and the extent to what alternative causal explanations were considered. Reports with significant links (p value .05) were systematically selected from 2 electronic databases. Twenty-five studies were identified. Risk measures were reported in 8 studies, and all of them presented weak associations. The impact of at least 1 competing explanations was analyzed in 32% of studies, but adjustment was considered not adequate in half of them. The evidence on dentistry as a profession with potential risk for development of MSKDs remains questionable. Further research is needed to more carefully elucidate the risk and the impact of MSKDs in this particular occupational group.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part III - Pain and dysfunction outcomes

47 end-stage TMJ patients with high occlusal plane angulation, treated with TMJ custom-fitted total joint prostheses and simultaneous maxillo-mandibular counter-clockwise rotation were evaluated for pain and dysfunction presurgery (T1) and at the longest follow-up (T2). Patients subjectively rated their facial pain/headache, TMJ pain, jaw function, diet and disability. Objective functional changes were determined by measuring maximum interincisal opening (MIO) and laterotrusive movements. Patients were divided according to the number of previous failed TMJ surgeries: Group 1 (0-1), Group 2 (2 or more). Significant subjective pain and dysfunction improvements (37-52%) were observed (<0.001). MIO increased 14% but lateral excursion decreased 60%. The groups presented similar absolute changes, but Group 2 showed more dysfunction at T1 and T2. For patients who did not receive fat grafts around the prostheses and had previous failure of proplast/teflon and or silastic TMJ implants, more than half required surgery for TMJ debridement and removal of foreign body giant cell reaction and heterotopic bone formation. End-stage TMJ patients can be treated in one operation with TMJ custom-made total joint prostheses and maxillo-mandibular counter-clockwise rotation, for correction of dentofacial deformity and improvement in pain and TMJ dysfunction; Group 1 patients had better results than Group 2 patients.

MASSETERIC ELECTROMYOGRAPHIC SILENT PERIOD DURATION IN PATIENTS WITH TEMPOROMANDIBULAR-JOINT DYSFUNCTION

1. The present study compared the duration of the electromyographic silent period (SP) of the masseter muscles elicited by chin-tapping in normal asymptomatic adults (N = 39) and in a group with symptoms of temporomandibular joint dysfunction (TMJD) (N = 31).2. EMG activity was recorded from right (RM) and left (LM) masseter muscles using bipolar surface electrodes coupled to a DISA 1500 EMG-System. During maximal clenching, ten taps were applied downwards to the chin with a reflex hammer.3. The mean SP durations obtained for the normal group were 25.45 +/- 4.20 ms (RM) and 25.33 +/- 4.18 ms (LM), whereas the TMJD group presented significantly greater values (P < 0.01, Student t-test) of 41.89 +/- 12.94 ms (RM) and 42.40 +/- 12.99 ms (LM). The upper limits of normality calculated for RM and LM were 32.36 ms and 31.21 ms, respectively. Eighty-four percent of patients with TMJD showed SP durations above these limits.4. The results indicate that the measurement of masseteric SP duration may be used as an objective diagnostic method of TMJ disorders, provided that borderline values are interpreted with caution along with clinical impressions.

Myofascial Pain Syndrome as a Contributing Factor in Patients with Chronic Headaches

Objectives: The purpose of this study was to evaluate the prevalence of active and latent trigger points [TrPs], as well as analyze the prevalence of different types of headaches in chronic headache patients. The active and latent TrPs in muscles of orofacial and cervical regions were also evaluated. Methods: There were 290 subjects who participated in this study. Trigger points were identified according to Simons et al.'s diagnostic criteria. Trigger points were considered active if subjects recognized the evoked referred pain as their familiar headache. If the evoked referred pain was not recognized as the familiar headache, the TrPs were considered latent. Differential diagnosis for headache was performed on the basis of International Headache Society criteria. Results: Trigger points could be diagnosed in 77 percent of patients and, in 89 percent of these, active TrPs were found. Muscle tenderness could be observed in 22 percent of patients, and only 1 percent patients were muscle-pain-free. The headache diagnosis showed that 26 percent had tension-type headache, 13 percent had migraine, and 61 percent had combined episodes of tension-type headache and migraine. The highest number of TrPs were found in temporalis [N = 159], masseter [N = 126], and occiptofrontalis [N = 113] muscles. Active TrPs were more frequent in temporalis and occiptofrontalis muscles. Conclusions: Subjects with chronic headaches had a higher prevalence of TrPs, and headache complaints could be reproduced during stimulation of active TrPs that were localized more frequently in temporalis and occiptofrontalis muscles. The presence of TrPs may be a contributing factor in the initiation and/or perpetuation of chronic headaches.

Alguns aspectos funcionais da articulação temporomandibular.

The authors emphasize the some functional characteristics of the Temporomandibular join, TMJ, and were made comparative study of the auscultatory and sphymografic techniques to TMJ examination. The findings shown that the auscultatory technique furnished important dates to preliminary diagnosis of the TMJ disfunction.

Hemoglobin as AS/alfa talassemia - Importância diagnóstica

Sickle Cell disease is a generic term for a group of genetic disorders characterized by the predominance of hemoglobin S. These disorders include Sickle Cell anemia, the Sickle Cell beta Thalassemia syndromes and Hemoglobinopathies in which hemoglobin S is in association with another abnormal hemoglobin, such as hemoglobin S/C. The Sickle Cell trait (hemoglobin AS) associated with Alpha Thalassemia presents alterations in the red blood cells morphology, usually absent in the heterozygous for this hemoglobin variant. The interaction between hemoglobin Sand alpha Thalassemia has been described as one of the factors responsible for the improvement in the clinical picture of homozygous of hemoglobin S (Sickle Cell Anemia), decreasing the number of episodes of pain. The genetic mechanisms of this influence are evaluated using molecular analyses of the human globin genes. With the objective of verifying the presence of alpha Thalassemia in heterozygous of hemoglobin S, with anemia, sent to the Laboratory of Hemoglobins, Department of Biology, UNESP, São José do Rio Preto, SP, we analyzed 1002 blood samples with Sickle Cell trait, in the period from 1990 to 1998. The samples were picked with EDTA 5% as anticoagulant, after previous authorization of the carriers. Appropriated counseling and management requires definitive diagnosis. For the laboratorial diagnosis the blood samples were submitted to electrophoretic procedures in alkaline and acid pH and cytological evaluation of hemoglobin H. The electrophoretic procedures confirmed the presence of hemoglobin AS. The cytological evaluation evidenced the presence of alpha Thalassemia. Of this total analyzed, 16(1,59%) blood samples presented the association between hemoglobin AS and alpha Thalassemia and two individuals belonged of the same family. Our results addressed us to suggest to the routine laboratories, that is important to accomplish the research of alpha Thalassemia among the Sickle Cell trait, with anemia, to verify the interaction with alpha Thalassemia, supplying to the carriers a important information on its hematological profile, genetic pattern of hemoglobinopathies and the appropriated counseling. Rev.bras.hematol.hemoter.,2000,22(3):388-394.

Mandible protrusion and decrease of TMJ sounds: An electrovibratographic examination

This study quantified by, electrovibratography, the amount of mandible protrusion required to decrease significantly temporomandibular joint (TMJ) vibratory energy as an aid in the diagnosis of the recapture of anteriorly displaced disk. Eighteen patients diagnosed as having anterior disk displacement with reduction and TMJ clicking were submitted to electrovibratographic examination at the first appointment and treated with a stabilizing appliance and anterior positioning appliance with 1 to 5 mm protrusion. Vibratory energy was checked in each of these positions. Baseline data were used as control. At the first appointment, the patients had vibrations with more elevated intensities at the middle and late phases of the mouth opening cycle. At only one clinical step, mandible protrusion was obtained with the anterior repositioning appliance, ranging from 1 to 5 mm protusion. At each new position, a new electrovibratographic exam was made. After the 5-mm mandibular projection, only 2 patients presented vibration, with means between 0.6 and 2.8 Hz. Data were analyzed statistically by ANOVA and Tukey's test (α=0.05). The outcomes of this study indicate that 3 mm is the minimum amount of mandible protrusion to significantly decrease the TMJ vibratory energy and to recapture the displaced articular disk.

Evaluation of temporomandibular joint noise in partially edentulous patients.

In order to evaluate the presence of TMD (temporomandibular disorder), dissatisfaction related to the use of removable partial dentures (RPD) and the effect of the treatment on temporomandibular joint noises, 13 female patients with Kennedy class I and II mandibular arch were selected. Another 13 young, asymptomatic, dentate patients, also female, were used as reference. After four years, 38.4% were found to have a moderate or severe degree of TMD. Over the four years, the degree of TMD increased in 46.15% of the patients, was not affected in 20.07%, while in 15.38% it decreased or the patients remained free from signs and symptoms. About 30% of the patients at the second year and 46% after the fourth year, had complaints regarding retention and stability. It was concluded that there is no relationship between TMD and the condition of partially edentulous Kennedy class I and II, but patient dissatisfaction increased after the second year and temporomandibular joint noise was reduced significantly with the replacement of the teeth.

Hallazgos clínico-radiológicos de la articulación temporomandibular en pacientes con artritis reumatoide

Aim of present paper is to describe and to assess the Clinicoradiological findings of the temporomandibular joint (TMJ) in a group of patients diagnosed with rheumatoid arthritis (RA). Sample included 61 patients with a mean age of 54 years and 5 months. All of them were interrogated and clinically examined and then underwent to a radiographic examination of both TMJs, using the transcranial projection technique, with the closed mouth and in maximal opening. Study includes the TMJ syndrome founded such as pain, tumefaction, luxation, clicking, and a limited oral opening. The study of radiographic features showed the presence of changes in condyle surface and temporal fossa, in condylar motility, and articulation space. We conclude that in patients presenting with rheumatoid arthritis is frequent the presence of clinicoradiological findings in the TMJ, and that patient's age and gender and the activity level and the RA course time, are factors influencing in TMJs general status.

Effect of occlusal splint treatment on the temperature of different muscles in patients with TMD

Purpose: The aim of this study was to evaluate the effect of occlusal splint treatment on the temperature of masseter (inferior, intermediate and superior), anterior temporal, digastric and trapezius muscles in patients with temporomandibular disorder (TMD). Materials and methods: Thirty patients (6 male and 24 female) aged from 16 to 57 years (mean 37.8. ± 11.4 years) were selected. The patients were diagnosed with muscular TMD by clinical examination (application of Research Diagnostic Criteria questionnaire and physical examination). Occlusal splints in acrylic resin were inserted in all patients with a weekly follow-up. The superficial thermography (°C) on the both sides of the muscles was performed using a digital thermometer in a controlled temperature room. This procedure was performed before occlusal splint insertion (patient with pain) and after the completion of the treatment (patient without pain). The data were analyzed by 2-way repeated-measures ANOVA and means were compared by Tukey HSD test (P< .05). Results: After occlusal splint treatment a significant increase in temperature was observed in each muscle, both in the right and left sides. When the muscles were compared in the same period (before or after therapy) there was no significant difference among them. Conclusion: It can be concluded that the use of occlusal splint promoted a significant increase on the muscles temperature. There was symmetry in the temperature of muscles on the right and left sides both before and after the treatment. © 2010 Japan Prosthodontic Society.

Tracheostomy-dependent child with temporomandibular ankylosis and severe micrognathia treated by piezosurgery and distraction osteogenesis: Case report

Ankylosis of the temporomandibular joint in children is one the most difficult and complex conditions managed by oral and maxillofacial surgeons, and often leads to some facial deformity. Distraction osteogenesis of the mandible provides an excellent treatment for mandibular airway obstruction in children who do not respond to conservative measures, and allows for early removal of the tracheostomy. We report the case of a 1-year-old boy with severe micrognathia and temporomandibular ankylosis who was dependent on a tracheostomy; he was treated with piezosurgery and mandibular advancement by distraction osteogenesis. © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.