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TMJ Referring Doctors Guide

Abfraction lesions: myth or reality?
Rees JS, Jagger DC.
Division of Restorative Dentistry, Department of Oral and Dental Science, University of
Bristol Dental School, Bristol, England.

Loss of tooth substance in the cervical region is usually attributed to toothbrush abrasion,
erosion, or a combination of both factors. Recently the role of occlusal loading has become
increasingly prominent. It is suggested that high occlusal loads cause large cervical stress
concentrations, resulting in a disruption of the bonds between the hydroxyapatite crystals and
the eventual loss of cervical enamel. This process has been called noncarious cervical tooth
loss or abfraction. This article reviews the available evidence to support the thesis that
occlusal loading can contribute to the process of abfraction. It also reviews the potential
interactions between occlusal loading and erosion that may contribute to abfraction lesion

CLINICAL SIGNIFICANCE: It is important to recognize the potential role of
occlusal loading in the loss of cervical tooth tissue so that management of the occlusion can
be incorporated into a treatment plan for a patient with abfraction lesions.

Stresses at the cervical lesion of maxillary premolar–a finite element investigation.
Lee HE, Lin CL, Wang CH, Cheng CH, Chang CH.
School of Dentistry, Kaohsiung Medical University, 100 Shih-Chuen 1st Road, Kaohsiung
80708, Taiwan.

OBJECTIVES: The objective of this study was to use a three-dimensional (3-D) finite
element model to investigate normal stress distribution to substantiate the tooth flexure
mechanism. The study also compared the changes in the stresses by different occlusal loading
sites and directions.
METHODS: The 3-D finite element analysis was used. A maxillary
premolar was selected to construct the simulation model. The model was constructed step-bystep for convergence and validity. Seven load conditions for various load sites and different
directions were simulated to the model.
RESULTS: The maximal principal stress and minimal
principal stress distributions developed within the structures of seven load conditions were
output and their stress distributions on z-plane at the vertical midline were shown. The peak
tensile stress of the cervical area for various load conditions were compared and listed.
CONCLUSIONS: This study has shown that the presence of tensile stresses in the cervical
region of a maxillary premolar by various loading sites and different directions. The results
coincided with the stress-induced theory, hence sustaining it. The relationship of the affected
factors of leverage to the development of cervical abfraction lesions, was explored. Copyright
2002 Elsevier Science Ltd.

William R. Markesbery, M.D., William D. Ehmann, M.D., (and colleagues at the University
of Kentucky’s Sanders-Brown Center on Aging).

Drs. Markesbery’s and Ehmann’s experiments have shown that there are higher concentrations
of mercury in the autopsied brains of patients who died of Alzheimer’s than are present in the
autopsied brains of patients who did not have Alzheimer’s. In the Alzheimer’s patients’ brains,
there are also lower concentrations of selenium and zinc, the two chief mineral antagonists of
mercury. Markesbery and Ehmann have also demonstrated that there are higher
concentrations of mercury in the brains of people who have more and larger amalgam dental
fillings. Additional research is underway to link the presence of amalgam mlings more closely
with the incidence ofAlzheimer’s.

Trace Elements in Alzheimer’s Disease Brains
Wenstrup, D., Ehmann, W.D., and Markesbery W.R., “Trace Element Imbalances in Isolated
Subcellular Fractions of Alzheimer’s Disease Brains” Brain Research, 533 125-131 Elsevier
Science Publishers (1990).

ABSTRACT: Concentrations of 13 trace elements (Ag, Br, Co, Cr, Cs, Fe, Hg, K, Na, Rb, Sc,
Se, Zn) in isolated subcellular fractions (whole brain, nuclei, mitochondria, microsomes) of
temporal lobe from autopsied Alzheimer’s disease (AD) patients and normal controls were
determined utilizing instrumental neutron activation analysis. Comparison ofAD and controls
revealed elevated Br (whole brain) and Hg (microsomes) and diminished Rb (whole brain,
nuclear and microsomes), Se (microsomes) and Zn (nuclear) in AD. The elevated Br and Hg
and diminished Rb are consistent with our previous studies in AD bulk brain specimens.
Comparison of element ratios revealed increased Hg/Se, Hg/Zn and Zn/Se mass ratios in AD.
Se and Zn playa protective role against Hg toxicity and our data suggest that they are utilized
to detoxify Hg in the AD brain. Overall our studies suggest that Hg could be and important
toxic element in AD. Whether Hg deposition in AD is a primary or secondary event remains
to be determined.

PlastReconstr Surg. 1993 Jun;91 (7): 1187-95; discussion 1196-7.
Cervical spine subluxation associated with congenital muscular torticollis and craniofacial

Slate RK, Posnick JC, Armstrong DC, Buncic JR.
Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.

The relationship between craniofacial asymmetry, congenital muscular torticollis, and cervical
spine subluxation was examined in a study of 30 children who presented to our Craniofacial
Program from 1987 through 1990. Twenty-six of the 30 patients had craniofacial asymmetry
and muscular torticollis without true suture synostosis documented by head and neck CT
scans. These 26 patients had positional skull molding with consistent flattening of the
contralateral occipitoparietal region and the ipsilateral fronto-orbital region relative to the side
of the torticollis. Thirteen of the 26 patients also were found to have a CI-C2 subluxation. Cl
was rotated forward of C2 on the side contralateral to the muscular torticollis in 12 of 13
patients. None of the patients with subluxation had neurologic deficits or required spinal
stabilization. Ophthalmologic evaluations demonstrated amblyopia (4 patients) and horizontal
strabismus (1 patient), both thought to be coincidental, with no evidence of nystagmus in any
case. Seven of the 26 patients required surgical therapy for their neck muscle tightness, while
the remainder responded to physiotherapy. Only 2 of the 26 patients underwent cranio-orbital
reshaping for correction of their upper face asymmetry. Recognition of cervical subluxation in
patients with congenital muscular torticollis may help to explain residual head-neck posturing
problems even after successful neck muscle therapy.

Neck-tongue Syndrome
Cameron Borody, BSc, DC
Dr. Cameron Borody, Assistant Professor, Clinical Education, Canadian Memorial
Chiropractic College, 1900 Bayview Avenue, Toronto, Ontario M4G 3E6, Canada; Email:

OBJECTIVE: To discuss a case of neck-tongue syndrome (NTS) affecting a dancer/figure
skater, review literature summarizing the pathogenesis and treatment, and offer new
categorization of neck-tongue syndrome. CLINICAL FEATURES: A 24-year-old female dancer/skater sought treatment for recurrent episodes of right-sided upper neck pain with associated ipsilateral numbness of her tongue following brisk active rotation. Radiographs revealed a narrowing of the left para-odontoid
space. Physical examination revealed a mildly painful restriction in rotation at Cl-2 with no
apparent muscular hypertonicity. INTERVENTION AND OUTCOME: The patient had sought chiropractic treatment for this condition several times since she was 8 years old. Diversified chiropractic adjustments were
applied to restrictions throughout the cervical spine as determined by the clinician. No other
interventions were employed. The patient experienced significant improvement in frequency
and intensity of the neck and tongue symptoms following spinal manipulative therapy applied
to her cervical spine.CONCLUSION: There are 2 categories of NTS: complicated NTS due to the presence of an
underlying disease process (inflammatory or degenerative) and uncomplicated NTS
(idiopathic or trauma-related). This case report is of uncomplicated NTS that responded
favorably to spinal manipulative therapy directed at the cervical spine. In the absence of upper
cervical instability, spinal manipulative therapy appears to be beneficial and should be
considered in all cases of uncomplicated NTS.

Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller
University, 1230 York Avenue, New York, New York 10021 USA

Adaptation in the face of potentially stressful challenges involves activation of neural,
neuroendocrine and neuroendocrine-immune mechanisms. This has been called “allostasis” or
“stability through change” by Sterling and Eyer (Fisher S., Reason 1. (eds): Handbook of Life
Stress, Cognition and Health. 1. Wiley Ltd. 1988, p. 631), and allostasis is an essential
component of maintaining homeostasis. When these adaptive systems are turned on and
turned off again efficiently and not too frequently, the body is able to cope effectively with
challenges that it might not otherwise survive. However, there are a number of circumstances
in which allostatic systems may either be overstimulated or not perform normally, and this
condition has been termed “allostatic load” or the price of adaptation (McEwen and Stellar,
Arch. Int. Med. 1993; 153:2093.). Allostatic load can lead to disease over long periods. Types
of allostatic load include (l) frequent activation of allostatic systems; (2) failure to shut off
allostatic activity after stress; (3) inadequate response of allostatic systems leading to elevated
activity of other, normally counter-regulated allostatic systems after stress. Examples will be
given for each type of allostatic load from research pertaining to autonomic, CNS,
neuroendocrine, and immune system activity. The relationship of allostatic load to genetic and
developmental predispositions to disease is also considered.

Laryngoscope. 2003 Oct;I13(10):1658-71.
Autonomic related vertigo.
Pappas DG Jr.
Pappas Ear Clinic, 2937 7th Avenue South, Birmingham, AL 35233, USA.

OBJECTIVES: To demonstrate clinical evidence that vestibular symptomatology can occur in
relation to autonomic dysfunction. Characterization of clinical findings and treatment
response would then allow autonomic related vertigo to be differentiated from other
vertiginous conditions that present in a like manner. STUDY DESIGN: This was a
retrospective review of 113 patients that described symptoms consistent with spontaneous,
rotational vertigo and autonomic dysfunction. METHODS: Vestibular, otologic, and
autonomic symptoms are presented along with the results of audiologic, orthostatic, and
autonomic testing. Medical management included fluid loading, dietary changes, exercise,
and patient education. Treatment results were analyzed according to the effectiveness in
control of vestibular and otologic symptoms. Results were compared with a control group that
demonstrated a similar vestibular and otologic presentation without autonomic
symptomatology. RESULTS: All patients described spontaneous, rotational vertigo, with
complete or substantial vertigo control obtained in 93 (85%) of 110 patients. Postural vertigo
and distinct lightheadedness were also documented in 53% and 97% of cases, respectively.
Vertigo failed to improve or worsened with prior treatment of low sodium diet or diuretic in
53 (91%) of 58 cases. Vertigo improvement was subsequently achieved in 48 (86%) of 56
cases with an autonomic treatment regimen. Long-term vertigo control was obtained in 56
(88%) of 64 patients followed for at least 18 months. Tinnitus was reported in 97 (86%)
patients, aural fullness in 93 (82%) patients, and subjective hearing loss (HL) in 46 (41%) of
111 cases. Bilateral tinnitus and aural fullness occurred in 65% and 63%, respectively.
Tinnitus improved with treatment in 56 (67%) of 84 patients, whereas aural fullness improved
in 59 (74%) of 80 patients. Autonomic symptoms included palpitations in 103 (91%) patients,
chronic fatigue in 102 (90%) patients, cold extremities in 91 (81%) patients, and previous
fainting in 72 (64%) patients. A history of mitral valve prolapse was documented in 51 (45%)
of cases and demonstrated with echocardiogram in 68 (93%) of the 73 patients tested.
Audiologic testing was normal in 104 (95%) of 109 patients, and electrococWeography was
abnormal in 42 (40%) of 105 patients. Orthostatic blood pressure and heart rate testing met
the criteria for orthostatic hypotension in 16 (15%) of 104 patients. Autonomic testing was
obtained in 34 cases, with orthostatic intolerance demonstrated in 33 (97%) patients and
orthostatic hypotension demonstrated in 13 (38%) patients. Overall, orthostatic hypotension
was documented through combined testing results in 23 (21%) of 107 patients. Vertigo was
reproduced during autonomic testing in 17 (77%) of 22 patients, and otologic symptoms were
reproduce in 9 (47%) of 19 patients. Comparison of the study population with a control group
without autonomic symptoms revealed statistically significant differences in orthostatic
testing and treatment results. There was no statistical difference noted in fmdings between
patients of this study that demonstrated or failed to demonstrate orthostatic hypotension.
CONCLUSIONS: There is a subgroup of patients with spontaneous vertigo who also
demonstrate symptoms and findings consistent with poor autonomic regulation. These
patients report vertigo improvement with a treatment strategy that aims to improve autonomic
dysfunction through expansion of effective circulating volume. Clinical findings and
treatment results of this study suggest an underlying autonomic influence in the production of
vertigo and otologic symptoms.

Autism, Asthma, Irritable bowel syndrome (lBS), strabismus and illness susceptibility: a case
study in chiropractic management. Amalu WC. Todays Chiropractic. September/October
1998. Pp. 32-47.
A 5-year-old female with autism, asthma, allergies, irritable bowel syndrome and left-sided
strabismus who was experiencing 25 violent temper episode per day, with each episode
lasting up to 20 minutes was referred for care. She also exhibited three episodes each day of
self-inflicted violent behavior, which included biting her arm, slapping her head and
repeatedly banging her head against a full-length mirror. She also had at least one episode of
violent behavior each day – hitting people, especially her mother. Speech was limited to a few
words such as “mama, dada, milk and walk.”
Chiropractic Management consisted of correction of the atlanto-occipital subluxation with the
patient adjusted in the knee-chest posture with contact to the posterior arch of atlas.
First week of care: After the first adjustment, patient had her first good night’s sleep since her
mother could remember. Violent temper episodes had reduced to 15 per day with de-crease in
intensity. Self-inflicted violent behavior was decreased in frequency. Her speech, vocabulary
and sleep patterns had improved.
Second week: one adjustment. Violent temper episodes at five per day. Right eye showed no
more signs of strabismus. Patient began speaking in sentences for the first time. Mother
reported a marked decrease in hyperactivity along with a desire to be touched and hugged
Third week: One adjustment. Violent temper episodes 2 per day with decreased intensity.
Mother stated there was little hyperactivity. Self-directed or outward violent behavior have
ceased. Irritable bowel syndrome was much improved.
Fourth week: no adjustments. All temper episodes, hyperactivity, violent behavior have
stopped. Sleeping through the night. Patient was evaluated by two therapists who declared the
diagnosis of autism was “incorrect.”
Week 5- 8: a mild return of symptoms, an adjustment was given, and symptoms abated.
Weeks 9-12: no adjustments. The IBS had almost completely resolved. Patient continued to
improve over next 8 months; no more asthma attacks.

Reduced cardiac parasympathetic activity in children with autism.
Brain Dev. 2005 Oct;27(7):509-16
Ming X, et al
Department of Neuroscience, New Jersey Medical School,
Many of the clinical symptoms of autism suggest autonomic dysfunction. results suggest that
there is low baseline cardiac parasympathetic activity with evidence of elevated sympathetic
tone in children with autism whether or not they have symptoms or signs of autonomic

Sjogren’s syndrome (SS), first described by Swedish ophthalmologist Henrik Sjogren in
1930, is a chronic inflammatory, autoimmune disorder characterized by diminished lacrimal
and salivary glands secretion resulting in keratoconjunctivitis sicca and xerostomia. One
factor instrumental in severe salivary gland damage and salivary flow decrement is radiation
therapy. Apoptosis, implicated in autoimmune diseases, has been shown to be responsible for
this damage. However, there are no studies investigating the effect of diagnostic radiation
(low dose) on salivary glands. A safe level of radiation has not been established thus far.
Diagnostic radiation has been used from 1896, but generally applied only from 1916. Dr.
Sjogren identified SS in 1930. It is possible that the introduction of X-rays for diagnostic
purposes is associated with SS onset. Available data show drastically reduced use of
diagnostic dental radiation in developing countries and a concomitantly drastically reduced or
lack of SS in these countries. In countries like India with a population of 1.1billion (health
care level II country), primary SS has been reported to be rare (total of 27 and 23 primary SS
and secondary SS patients respectively reported thus far), while a health care level I country
like USA, with a population of 300million, there are about 2-4million SS patients. Health
care level IV countries do not have a single reported case of SS. There is also evidence for
ultraviolet radiation inducing subcutaneous lupus erythematosus, an autoimmune disorder.

Occupational toxic risks in dental laboratory technicians
Leon Choel1 *, Brigitte Grosgogeat 1, Denis Bourgeois 2, Jacques Descotes 3
1Laboratoire des Interfaces en Odontologie, EA 637, Faculte d’Odontologie, Lyon, France
2Laboratoire d’Analyse des Systemes de Sante, UMR 5823-CNRS, Faculte
dapos;Odontologie, Lyon, France
3Centre Antipoison, Hopital E. Herriot, Lyon, France
Dental laboratory technicians use a wide range of materials and techniques. They are thus
subject to occupational exposures of many different kinds. The aim of this review is to present
the circumstances of exposure, the related risks, and the epidemiological data available in the
literature. Exposures to metals, waxes, resins and silica can cause irritation or allergic
reactions, affecting either the skin or the respiratory tract. The risks of benign pneumoconiosis
induced by hard metals are well documented. A prevalence of 15.4% after 20 or more years of
exposure has been reported, whereas the prevalence in the general population is less than 1%.
Malignant pneumoconiosis is caused by dust from crystalline silica, asbestos or beryllium.
Silicosis is the most common occupational disease among dental technicians, while for
berylliosis the risk is not well documented. Isolated cases of systemic autoimmune diseases
have been observed. No study has yet demonstrated a link between these diseases and
occupational exposure of dental technicians. Silica is known to provoke systemic
scleroderma, but its role in prosthetists remains to be established. The first steps in prevention
are the identification, classification and evaluation of exposure and the effects of that
exposure on the health of exposed workers. Reduction or elimination of exposure by
collective or individual protective measures are the best modalities of prevention.

Brazilian Oral Research
Print ISSN 1806-8324
PINTO, Cristiane Franco, OLIVEIRA, Rogrio de, CAVALLI, Vanessa et al. Peroxide
bleaching agent effects on enamel surface microhardness, roughness and morphology. Braz.
oral res., Oct.lDec. 2004, vol.18, noA, p.306-311. ISSN 1806-8324.
The aim of this study was to evaluate the surface roughness, microhardness and morphology
of human enamel exposed to six bleaching agents (at baseline and post-treatment). Human
dental enamel samples were obtained from human third molars and randomly divided into
seven groups (n = 11): control, Whiteness Perfect – 10% carbamide peroxide (10% CP),
Colgate Platinum – 10% CP, Day White 2Z – 7.5% hydrogen peroxide (7.5% HP), Whiteness
Super – 37% CP, Opalescence Quick – 35% CP and Whiteness HP – 35% HP. Bleaching
agents were applied according to manufacturers’ instructions. The control group remained not
treated and stored in artificial saliva. Microhardness testing was performed with a Knoop
indentor and surface roughness was analyzed with a profilometer. Morphologic observations
were carried out with scanning electron microscopy (SEM). Results were statistically
analyzed by two-way analysis of variance and Tukey’s test (5%), and revealed a significant
decrease in microhardness values and a significant increase in surface roughness postbleaching.
Changes in enamel morphology after bleaching were observed under SEM. It was
concluded that bleaching agents can alter the microhardness, roughness and morphology of
dental enamel surface

Brazilian Dental Journal
Print ISSN 0103-6440
OLIVEIRA, Rogrio de, PAES LEME, Adriana Franco and GIANNINI, Marcelo. Effect of a
carbamide peroxide bleaching gel containing calcium or fluoride on human enamel surface
microhardness. Braz. Dent. 1., May/Aug. 2005, vol. 16, no.2, p.103-106. ISSN 0103-6440.
This in vitro study evaluated the surface microhardness of human enamel submitted to
bleaching with 10% carbamide peroxide (CP) containing calcium or fluoride. Ninety-eight
dental blocks (5 x 5 mm2) with polished enamel surfaces were randomly assigned to 7
treatment groups (n=14), as follows: without bleaching and storage in artificial saliva
(control); 10% CP; 10% CP + 0.05% calcium; 10% CP + 0.1% calcium; 10% CP + 0.2%
calcium; 10% CP + 0.2% fluoride; and 10% CP + 0.5% fluoride. During 14 days, enamel
surfaces were daily exposed to a 6-h bleaching regimen followed by storage in artificial
saliva. Surface microhardness was measured before (baseline), during (7th day), immediately
after bleaching (14th day) and 1 week post bleaching. Data were analyzed by two-way
ANOVA and Tukey’s test (p<0.05). All treatments reduced SM significantly during the bleaching cycle (7th day), immediately after bleaching (14th day) and 1 week post bleaching, compared to baseline and to the unbleached control group. In conclusion, in spite of the addition of calcium and fluoride, all bleaching treatments affected the enamel surface microhardness.

Bruxism in children with nasal obstruction
INTRODUCTION: Bruxism is characterized by repeated tooth grinding or clenching. The
condition can occur in all age ranges and in both genders, being related or not to other oral
habits. OBJECTIVE: The objective of the present study was to investigate the occurrence of
bruxism in children with nasal obstruction and to determine its association with other factors.
METHODS: Sixty children with nasal obstruction seen at the Otorhinolaryngology Outpatient
Clinic of the University Hospital of RibeirA£o Preto participated in the study. The data were
obtained using a pre-established questionnaire applied to the person responsible and by
orofacial evaluation of the patient. The participants were divided into two groups: group with
bruxism (GB) as reported by the relatives and with the presence of tooth wear detected by
clinical evaluation, and group without bruxism (GWB), consisting of children with none of
the two symptoms of bruxism mentioned above. RESULTS: The presence of bruxism
exceeded its absence in the sample studied (65.22%). There was no significant difference
(P<0.05) between groups regarding gender, phase of dentition, presence of hearing diseases, degree of malocclusion, or child behavior. CONCLUSION: Bruxism and deleterious oral habits such as biting behavior (objects, lips and nails) were significantly present, together with the absence of suction habits, in the children with nasal obstruction. Authored by Grechi TH, Trawitzki LV, de Fe1A-cio CM, Valera FC, Alnselmo-Lima WT. Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Faculty of Medicine of RibeirA£o Preto, University ofSA£o Paulo, Avenida Bandeirantes 3900, 14096900 RibeirA£o Preto, SA£o Paulo, Brazil. Published in Int J Pediatr Otorhinolaryngol. 2008 Jan 28 Principles for the management of bruxism* F. LOBBEZOO*, 1. van der ZAAG*, M. K. A. van SELMS*, H. L. HAMBURGER t & M. NAEIJE* *Department of Oral Function, Academic Centre for Dentistry Amsterdam (ACTA) and t Departments of Neurology and Clinical Neurophysiology, and Amsterdam Center for SleepWake Disorders, Slotervaart General Hospital, Amsterdam, The Netherlands Correspondence to Dr Frank Lobbezoo, Department of Oral Function, Academic Centre for Dentistry Amsterdam (ACTA), Louwesweg 1, 1066 EA Amsterdam, The Netherlands. Email: f.1obbezoo@acta.n1 Summary The management of bruxism has been the subject of a large number of studies. A PubMed search, using relevant MeSH terms, yielded a total of 177 papers that were published over the past 40 years. Of these papers, 135 were used for the present review. Apparently, research into bruxism management is sensitive to fashion. Interest in studying the role of occlusal interventions and oral splints in the treatment of bruxism remained more or less constant over the years: between 1966 and 2007, approximately 4~0% of the papers dealt with this subject. The percentage of papers that dealt with behavioural approaches, on the other hand, declined from >60% in the first 2 decades (1966-1986) to only slightly >10% in
the most recent decade (1997-2007). In the latter period, >40% of the papers studied the role
of various medicines in the treatment of bruxism, while in the preceding decade (1987-1996),
only approximately 5%.ofthe studies dealt with the pharmacological management of bruxism.
Unfortunately, a vast majority of the 135 papers have a too low level of evidence. Only 13%
of the studies used a randomized clinical trial design, and even these trials do not yet provide
clinicians with strong, evidence-based recommendations for the treatment of bruxism. Hence,
there is a vast need for well-designed studies. Clinicians should be aware of this striking
paucity of evidence regarding management of bruxism.

Dermatologic Therapy
Volume 15 Issue 3, Pages 287 – 291
Burning mouth syndrome: differential diagnosis
Miriam Grushka,* Joel B. Epstein, t & Meir Gorsky ~
*William Osler Health Center, Etobicoke Campus, Toronto, Ontario, Canada, and Clinical
Instructor of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut,
t Department of Oral Medicine, University of Washington, Seattle, Washington, and
Department of Dentistry, Vancouver Hospital and Health Sciences Center, and MedicalDental
Staff, British Columbia Cancer Agency, Vancouver, British Columbia, Canada, and ~
Department of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Burning mouth syndrome (BMS) has been defined as a burning pain of the tongue or other
oral mucous membranes in an individual who exhibits no clinical signs and no related
laboratory findings. Recently this concept has been disputed as being too restrictive; it has
been suggested instead that BMS may exist coincidentally with other oral conditions. BMS
may be linked to other orofacial pain problems, such as atypical odontalgia (AO),
temporomandibular disorder (TMD), and other sensory dysesthesia.

Atrophic Glossitis From Vitamin B12 Deficiency: A Case Misdiagnosed as Burning Mouth
Julia S. Lehman,* –Alison J. Bruce, and –Roy S. RogersIII-*
University of Wisconsin Medical School, Madison, WI.
tMayo Clinic, Rochester, MN.
Background: Glossodynia, or painful sensation of the tongue, can have a spectrum of
etiologies, such as local infection, trauma, nerve damage, glossitis, or the enigmatic
neuropathic pain syndrome, burning mouth disorder (BMD; also known as burning mouth
syndrome). Careful history-taking, physical examination, and appropriate laboratory
screening can differentiate these causes of glossodynia and direct further therapy.
Methods: A 73-year-old woman presented with several months of glossodynia having
previously been diagnosed by her primary care physician with primary BMD. Subsequently,
she consulted an otolaryngologist, who pursued further diagnostic evaluation.
Results: Examination revealed the presence of a beefy, red, smooth tongue, and further
laboratory evaluation yielded a low serum vitamin B12 level and macrocytosis. Three months
of oral vitamin B12 supplementation led to partial restoration of serum vitamin B12 levels
and a modest improvement in symptoms. Her final diagnoses were atrophic glossitis and
glossodynia secondary to vitamin B12 deficiency, most likely due to pernicious anemia.
Conclusions: The results of this case have important clinical implications for the diagnostic
evaluation and management of patients with glossodynia and apparent BMD. Pathogenic
mechanisms of nutrient deficiency in atrophic glossitis are discussed.

Dermatologic Therapy
Volume 15 Issue 3, Pages 287 – 291
Burning mouth syndrome: differential diagnosis
Miriam Grushka,* Joel B. Epstein, t & Meir Gorsky ~
*William Osler Health Center, Etobicoke Campus, Toronto, Ontario, Canada, and Clinical
Instructor of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut,
t Department of Oral Medicine, University of Washington, Seattle, Washington, and
Department of Dentistry, Vancouver Hospital and Health Sciences Center, and MedicalDental
Staff, British Columbia Cancer Agency, Vancouver, British Columbia, Canada, and ~
Department of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
Burning mouth syndrome (BMS) has been defined as a burning pain of the tongue or other
oral mucous membranes in an individual who exhibits no clinical signs and no related
laboratory findings. Recently this concept has been disputed as being too restrictive; it has
been suggested instead that BMS may exist coincidentally with other oral conditions. BMS
may be linked to other orofacial pain problems, such as atypical odontalgia (AO),
temporomandibular disorder (TMD), and other sensory dysesthesia.

Atrophic Glossitis From Vitamin B12 Deficiency: A Case Misdiagnosed as Burning Mouth
Julia S. Lehman,* –Alison J. Bruce, and –Roy S. RogersIII-*
University of Wisconsin Medical School, Madison, WI.
tMayo Clinic, Rochester, MN.
Background: Glossodynia, or painful sensation of the tongue, can have a spectrum of
etiologies, such as local infection, trauma, nerve damage, glossitis, or the enigmatic
neuropathic pain syndrome, burning mouth disorder (BMD; also known as burning mouth
syndrome). Careful history-taking, physical examination, and appropriate laboratory
screening can differentiate these causes of glossodynia and direct further therapy.
Methods: A 73-year-old woman presented with several months of glossodynia having
previously been diagnosed by her primary care physician with primary BMD. Subsequently,
she consulted an otolaryngologist, who pursued further diagnostic evaluation.
Results: Examination revealed the presence of a beefy, red, smooth tongue, and further
laboratory evaluation yielded a low serum vitamin B12 level and macrocytosis. Three months
of oral vitamin B12 supplementation led to partial restoration of serum vitamin B12 levels
and a modest improvement in symptoms. Her final diagnoses were atrophic glossitis and
glossodynia secondary to vitamin B12 deficiency, most likely due to pernicious anemia.
Conclusions: The results of this case have important clinical implications for the diagnostic
evaluation and management of patients with glossodynia and apparent BMD. Pathogenic
mechanisms of nutrient deficiency in atrophic glossitis are discussed.

Journal of Oral Rehabilitation
Volume 9 Issue 1, Pages 45 – 51
A comparison of centric relation with maximum intercuspation based on quantitative
1. D. Buxbaum, F. J. Parente, W. O. Ramsey 1 L. M. Staling 1
University of Maryland School of Dentistry, Baltimore, Towson State University, Towson
Correspondence to Dr Jerome D. Buxbaum, Department of Physiology, University of
Maryland School of Dentistry, Baltimore, Maryland 21201, U.S.A.
A comparison of centric relation with maximum intercuspation based on quantitative
The study concerned the nature of the alterations, if any, in muscle activity demonstrable
when the mandible shifts from maximum intercuspation into its most retruded physiological
relation (i.e. centric relation).
An integrator-averager was used to determine IlV average amplitude from masseter and
temporal muscles in two maxillo-mandibular positions, centric relation and maximum
intercuspation, and three modes, first contact occlusion, chewing and swallowing. Vertical
reference marks on the cuspids were used to quantitate horizontal deviation from maximum
intercuspation to centric relation. Data were obtained from twelve subjects and analysed for
Results demonstrated a significant increase in IlV in all centric relation positions. Statistics
yielded an F value of 5.88258 with a probability of 0005. Results suggest critical limitations
in reliance on centric relation as a reference position during clinical therapy.

: Cranio. 1993 Jul; 11 (3): 178-83.
A comparison of electromyographic activity between anterior repositioning splint therapy and
a centric relation splint.
Williamson EH, Navarro EZ, Zwemer JD.
Medical College of Georgia in Augusta.
The purpose of this study was to compare the electromyographic activity of masticatory
muscles (temporal and masseter) with the use of an anterior repositioning splint and a centric
relation superior repositioning splint. Twenty-six consecutive patients, who referred with the
chief complaint of temporomandibular pain and/or headache were selected from one of the
author’s practices. All these subjects were diagnosed as having internal derangement of the
temporomandibular joint. Ten normal subjects were used as controls. Surface
electromyographic recordings were taken of each subject prior to the beginning of clinical
therapy for the patients. The results show significantly less masseter and temporal muscle
activity with anterior repositioning splint therapy compared to the centric relation superior
repositioning splint therapy.

Clark MR, Sullivan MD, Katon WJ, Russo JE, Fischl M, Dobie RA, Voorhees R. Psychiatric
and medical factors associated with disability in patients with dizziness. Psychosomatics
1995; 34(5): 409-415.
Abstract: Dizziness is a common patient symptom and often remains medically unexplained
even after an extensive work-up. The otologic disorders, psychiatric disorders, and functional
disability of 75 patients presenting with dizziness to a community otolaryngology practice
were assessed in 1991. The patients were classified according to the presence or absence of at least one current DSM-III-R psychiatric disorder and the presence or absence of a peripheral
vestibular disorder. Decrements in mental health and role functioning, and increases in bodily
pain and hypochondriacal focus were significantly associated with the presence of a
psychiatric disorder and whether the etiology of dizziness was due to a peripheral vestibular

Clark MR. Psychiatric and otologic diagnoses in patients complaining of dizziness. Archives
ofIntemal Medicine 1993; 143(12): 1479.
BACKGROUND: Dizziness is a common and disabling symptom in primary care practice,
especially among the elderly. Though there are many organic causes of dizziness, the results
of medical workups are negative in the majority of patients. METHODS: A total of 75
patients with dizziness who were referred to a community otolaryngology practice received a
structured psychiatric diagnostic interview (National Institute of Mental Health Diagnostic
Interview Schedule) and questionnaires that assessed psychological distress as well as a
complete otologic evaluation, including electronystagmogram. Patients with evidence of a
peripheral vestibular disorder were compared with those without such evidence. RESULTS:
While psychiatric diagnoses were present in both those with and without evidence of a
peripheral vestibular disorder, those without such evidence had a greater mean number of
lifetime psychiatric diagnoses as defmed by the Diagnostic and Statistical Manual of Mental
Disorders, Revised Third Edition, and specifically, a greater lifetime prevalence of major
depression and panic disorder. This group also more frequently met criteria for somatization
disorder, had more current and lifetime unexplained medical symptoms, and had more severe
current depressive, anxiety, and somatic symptoms. CONCLUSIONS: Psychiatric diagnoses
are common among patients with dizziness referred for otologic evaluation who do not show
evidence of a peripheral vestibular disorder. Specific psychiatric disorders should be part of
the differential diagnosis of patients who present with dizziness.

: J Rheumatol. 2003 Aug;30(8):1841-5.
Oral symptoms associated with fibromya1gia syndrome.
Rhodus NL, Fricton J, Carlson P, Messner R.
Division of Oral Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA.
OBJECTIVE: Studies have described oral problems associated with fibromyalgia syndrome
(FM), including sicca, oral ulcerations, and orofacial pain. We evaluated the prevalence and
profile of various oral symptoms in a population of patients diagnosed with FM. METHODS:
Subjects diagnosed with FM by American College of Rheumatology criteria (n = 67; all
women, mean age +/- SEM 47.6 +/- 2.3 yrs) were enrolled in the study after meeting strict
exclusion criteria (i.e., oral mucosal conditions, Sjogren’s syndrome, anemia, inflammatory
bowel syndrome or other gastrointestinal disturbances, and other disorders that may manifest
oral symptoms). Subjective oral evaluations were carried out for each subject, including oral
pain (Melzack scale) for glossodynia, throbbing, aching, etc.; temporomandibular joint
dysfunction (TMD); xerostomia (including intake of fluids, functional problems, etc.);
dysphagia; dysgeusia; and information about frequent oral ulcerations or lesions.
Psychological tests included Beck Depression Scale (BDS) and Spielberger Anxiety Scale
(SAS) were administered. RESULTS: The results indicated a significant prevalence in some
subjects’ oral symptoms, compared to age and sex matched control data (mean +/- SEM) for
xerostomia 70.9% vs 5.7% (p < 0.001); glossodynia 32.8% vs 1.1% (p < 0.001); TMD 67.6% vs 20% (p < 0.01); dysphagia 37.3% vs 0.4% (p < 0.001); dysgeusia 34.2% vs 1.0% (p < 0.001). Other findings were not significantly different from controls: oral ulcerations/lesions 5.1% vs 4.4% (NS); BDS 34% vs 30% (NS); SAS 21% vs 19% (NS). The average visual analog scale (100 mm) for burning pain was 53.0 +/- 5.6 (p < 0.001). Anxiety and depression scores were no different in the FM subjects compared to controls with chronic pain conditions. CONCLUSION: These data indicate that patients with FM have significantly increased prevalence of xerostomia, glossodynia, dysphagia, dysgeusia, and TMD compared to controls, with no significant difference in clinical oral lesions or psychological status. Yohji Harasawaa, Makoto Inouea, b, Corresponding Author Contact Information, E-mail The Corresponding Author, Sajjiv Ariyasinghec, Kensuke Yamamuraa and Yoshiaki Yamadaa aDivision of Oral Physiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8514, Japan bDivision of Dysphagia Rehabilitation, Department of Oral Biological Sciences, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8514, Japan cDepartment of Basic Sciences, Faculty of Dental Sciences, University of Peradeniya, Peradeniya 20400, Sri Lanka Changes in reflex responses in the genioglossus (GG) muscle evoked by electrical stimulation of the inferior alveolar nerve and GG muscle tone (background activity, BGA) were investigated during sleep-wakefulness stages in rabbits. The GG muscle showed two types of electromyographic activity patterns: a respiration-related phasic activity and non-respiration- related activity. GG reflex responses and BGA exhibited a stage-dependent decrease as they were constantly suppressed from quiet wakefulness to non-rapid eye movement sleep to rapid eye movement sleep (REMS). Degree of suppression of reflexes was much larger than that of BGA regardless of GG activity patterns. When amplitude of reflex responses was compared between with and without rapid eye movements during REMS, no difference between the conditions was noted. These results suggest that excitability of the GG muscle is affected by sleep stages by not only a modulation of excitability in motoneurons but also in interneurons involved in the reflex arc.

The History of Muscle Dysfunction and SEMG
Jeffrey R. Cram, PhD and Maya Durie, MEd, CMT
The history of muscle pain and dysfunction is viewed through the lens of a four factor theory
of histologic (tissue related) issues, psychologic (emotional) issues, sensory motor
(movement) issues, and biomechanical (postural) issues. The historical antecedents of both
bodywork and surface electromyography are reviewed.
Note: Parts of this article have appeared in The History of SEMG, Jour App Psychophys and
Biof, In Press. Humans have had to deal with sore muscles since the beginning of time.
Initially, muscle assessments and treatments were conducted by hand, and during the last
century, the use of electronic instruments came into play.
To put muscle function and the clinical use of Surface electromyography (SEMG) into a
perspective of history, is seems prudent to utilize a broad nomothetic net, or conceptual
framework. In Clinical Applications for Surface Electromyography, Kasman, Cram and Wolf
(1998) consider chronic muscle dysfunction from a four fold perspective: Histologic (Tissue
related issues); Psychologic (Psychophysiology and Emotions), Sensorimotor (Movement)
and Mechanical Dysfunction (Cumulative Trauma, Posture etc). In this article we will provide
a brief historical overview related to each of these four areas. This will provide a deep
background for the emergence of the clinical use of SEMG, including information on the
history of body work, psychophysiology, rehabilitation and the emergence of electricity and
SEMG instrumentation.

Electromyogr Clin Neurophysiol. 2006 Jul-Aug;46(4):217-22.
Electromyographic analysis of the masseter and temporal muscles in oralized deaf
Regalo SC, Vitti M, Semprini M, Rosa LB, Martinez FH, Santos CM, Hallak JE.
Morphology, Stomatology, and Physiology Department, Faculty of Dentistry of Ribeirao
Preto ofthe University of Sao Paulo (FORP-USP).
Deaf individuals show a number of difficulties related to the functionality of the
stomatognathic system, mainly by reason of the little or no use of facial musculature during
speech either due to the use of sign language or to the difficulty that these individuals have in
articulating words. The stomatognathic system muscles play important roles in functions such
as mastication, deglutition, and phonation. This study aimed to assess, by means of
computerized bilateral electromyography (EMG), masseter and temporal muscles of 12
oralized deaf individuals in clinical activities that involve part of this masticatory musculature
and compare this system’s functionality with that of 12 normal listening individuals,
performing the same activities. An 8-channel K6-I EMG Light Channel Surface
Electromyography device was used (Myo-Tronics Co.Seattle, WA, USA), in addition to
disposable double electrodes covered with silver chloride (Duotrodes; Myo-tronics Co.,
Seattle, WA) containing a conductor gel (Myogel- Myo-tronics Co., Seatlle, WA). The
averaged rectified EMG values were normalized with reference to the EMG amplitude
induced by a maximum bite force. The statistical analysis confirmed that there were any
significant differences between the groups, clinical activities, and muscles, and also effects
of interaction among them. The analysis made use of Variance Analysis (ANOVA). Significant
differences (p < 0.01) for both muscles were found among the clinical conditions, with deaf individuals showing greater electromyographic activity for both muscles for the clinical activity protrusion. Deaf individuals showed a lower muscular activity for clinical activities that demanded a greater masseter and temporal muscular activity such as mastication, mouth opening and closing, and dental compression. Greater electromyographic values were found for both deaf individuals and healthy controls during clinical activities of mastication and dental compression. Based on the obtained data, we concluded that deaf individuals showed a lower activity of the masticatory musculature than healthy individuals; the differences were significant at the level of p < 0.01 between the performed clinical activities; and all deaf individuals and healthy controls showed greater electromyographic values for mastication and dental compression.

Androgens and estrogens modulate the immune and inflammatory responses in rheumatoid
Cutolo M, Seriolo B, Villaggio B, Pizzorni C, Craviorto C, Sulli A.
AnnNY Acad Sci. 2002 Jun;966:131-42.
Laboratory and Division of Rheumatology, Department of Internal Medicine and Medical
Specialities, University of Genova, Genova, Italy.
Generally, androgens exert suppressive effects on both humoral and cellular immune
responses and seem to represent natural anti-inflammatory hormones; in contrast, estrogens
exert immunoenhancing activities, at least on humoral immune response. Low levels of
gonadal androgens (testosterone/dihydrotestosterone) and adrenal androgens
(dehydroepiandrosterone and its sulfate), as well as lower androgen/estrogen ratios, have been detected in body fluids (that is, blood, synovial fluid, smears, salivary) of both male and
female rheumatoid arthritis patients, supporting the possibility of a pathogenic role for the
decreased levels of the immune-suppressive androgens. Several physiological, pathological,
and therapeutic conditions may change the sex hormone milieu and/or peripheral conversion,
including the menstrual cycle, pregnancy, the postpartum period, menopause, chronic stress,
and inflammatory cytokines, as well as use of corticosteroids, oral contraceptives, and steroid
hormonal replacements, inducing altered androgen/estrogen ratios and related effects.
Therefore, sex hormone balance is still a crucial factor in the regulation of immune and
inflammatory responses, and the therapeutical modulation of this balance should represent
part of advanced biological treatments for rheumatoid arthritis and other autoimmune
rheumatic diseases.

Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994):
National Health and Nutrition Examination Survey (NHANES III).
Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA,
Braverman LE.
J Clin Endocrinol Metab. 2002 Feb;87(2):489-99.
Centers for Disease Control, National Center for Environmental Health, Division of
Emergency and Environmental Services, Atlanta, Georgia 30341, USA.
NHANES III measured serum TSH, total serum T(4), antithyroperoxidase (TPOAb), and
antithyroglobulin (TgAb) antibodies from a sample of 17,353 people aged> or =12 yr
representing the geographic and ethnic distribution of the U.S. population. These data provide
a reference for other studies of these analytes in the U.S. For the 16,533 people who did not
report thyroid disease, goiter, or taking thyroid medications (disease-free population), we
determined mean concentrations of TSH, T(4), TgAb, and TPOAb. A reference population of
13,344 people was selected from the disease-free population by excluding, in addition, those
who were pregnant, taking androgens or estrogens, who had thyroid antibodies, or
biochemical hypothyroidism or hyperthyroidism. The influence of demographics on TSH,
T(4), and antibodies was examined. Hypothyroidism was found in 4.6% of the U.S.
population (0.3% clinical and 4.3% subclinical) and hyperthyroidism in 1.3% (0.5% clinical
and 0.7% subclinical). (Subclinical hypothyroidism is used in this paper to mean mild
hypothyroidism, the term now preferred by the American Thyroid Association for the
laboratory findings described.) TgAb were positive in 10.4 +/- 0.5% and TPOAb, in 11.3 +/0.4%;
positive antibodies were more prevalent in women than men, increased with age, and
TPOAb were less prevalent in blacks (4.5 +/- 0.3%) than in whites (12.3 +/- 0.5%) (P < 0.001).

Curr Opin Otolaryngol Head Neck Surg. 2005 Oct;13(5):277-82.
Update on eustachian tube dysfunction and the patulous eustachian tube.
Grimmer JF, Poe DS.
Harvard Medical School Dept ORL, Children’s Hospital, 300 Longwood Avenue, Boston,
MA 02115, USA.
PURPOSE OF REVIEW: The purpose of this review is to summarize the recent knowledge
on eustachian tube dysfunction and the patulous eustachian tube. RECENT FINDINGS: A
clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus
alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators
identified within the eustachian tube and middle ear cells were causally linked with otitis
media with effusion. Increasing evidence was found that allergic disease and reflux may be
two of the most important contributors of tubal inflammation causing otitis media with
effusion. The adenoid size and proximity to the torus tubaris may also be important in
considering which patients with persistent otitis media with effusion may benefit from
adenoidectomy. Computed tomography scan has documented loss of soft tissue within the
cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic
approach to seal the tubal lumen has been found to be effective in relieving patulous
symptoms. SUMMARY: These studies suggest that allergic rhinitis and gastroesophageal
reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy
should also be considered in patients who have adenoids that obstruct the torus tubaris.
Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further
research is needed to identify a clinically useful test for eustachian tube dysfunction.

Laryngoscope. 2001 Feb;111(2):310-6.
The relationship between dental overbite and eustachian tube dysfunction.
McDonnell JP, Needleman HL, Charchut S, Allred EN, Roberson DW, Kenna MA, Jones D.
Children’s Hospital, Boston, Massachusetts, USA.
OBJECTIVE: The purpose of this study was to investigate the association between deep
dental overbite and eustachian tube dysfunction (ETD). DESIGN: Case-control study.
SETTING: Tertiary care pediatric otolaryngology outpatient clinic at the Children’s Hospital,
Boston, Massachusetts. PATIENTS: 105 patients between the ages of 2 and 6 years. STUDY
MEASUREMENTS: Dental overbite, overjet, and occlusal relationships were measured by an
observer who was unaware of ETD status. ETD was defmed as having ventilation tubes in
place or having the recommendation for ventilation tube placement by an attending pediatric
otolaryngologist. In addition, demographic information and medical and social histories were
prospectively recorded. RESULTS: In a multivariate logistic regression model, children with
deep bites were 2.8 times more likely to have ETD than those without deep bites (P = .03).
Other independent risk factors for ETD identified in this model were family history of otitis
media (OM) and age less than 3 years. CONCLUSIONS: Children with deep dental overbites
are at a significantly increased risk for developing ETD.

Am J Occup Ther. 2004 Sep-Oct;58(5):587-93.
A pilot study to investigate shoulder muscle fatigue during a sustained isometric wheelchair propulsion
effort using surface EMG.
Niemeyer LO, Aronow HU, Kasman GS.
The Foto Group, Montecito, California,
OBJECTIVE: The primary aim of this pilot study was to develop a testing protocol for
gathering shoulder muscle surface electromyography (EMG) data during a sustained
submaximal isometric wheelchair-propulsion effort. Of special interest was analysis of the
median frequency of the surface EMG signal power spectrum; a negative median frequency
shift during a sustained effort is an indicator of muscle fatigue. The long-term goal is to
improve our understanding of how fatigue and muscle imbalance might play a role in the
development of a broad array of upper-extremity overuse syndromes. METHOD: Participants
were a convenience sample of seven male manual-wheelchair users with spinal cord injury
and 14 able-bodied males. Surface EMG in six right-side shoulder muscles was recorded
while subjects resisted a static force equal to 60% of their maximum wheelchair-propulsion
strength until fatigued. Percent of maximum voluntary contraction and the median frequency
shift for each muscle were analyzed. RESULTS: The able-bodied group used a higher percent
of maximum than the manual-wheelchair group (p< .05), and a more pronounced negative median frequency shift was evident in the able-bodied group (p < .10). CONCLUSION: Patterns that emerged suggest that spectral analysis of the surface electromyographhic signal has promise as a clinically useful tool to authenticate muscle fatigue in the upper extremities during occupational performance. Such data in the future could be used to justify the need for and benefits of adapted performance techniques and assistive technology. J Physiol. 1991 Apr;435:547-58. Role of small diameter afferents in reflex inhibition during human muscle fatigue. Garland SJ. Department of Biomedical Sciences, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada. 1. Previous work has shown that the H reflex excitability of the human soleus motoneurones is reduced during fatigue and is accompanied by a corresponding decrease in electromyographic (EMG) activity during maximal voluntary contractions. These findings were consistent with the existence of a reflex whereby alpha-motoneurones are inhibited by sensory input from the fatigued muscle. 2. To elucidate the contribution of different-sized afferents in such reflex inhibition, compression of the sciatic nerve was used in an attempt to block large myelinated afferents prior to fatigue. 3. Fatigue of the soleus muscle was induced under ischaemic conditions by intermittent electrical stimulation at 15 Hz in ten healthy subjects. These subjects also participated in a control test in which the compression block was followed by ischaemia without fatigue. 4. Following nerve compression alone, both the mean maximal plantarflexion torque and the associated EMG for all ten subjects declined by 18.8 +/- 16.2% (S.D.) and 13.4 +/- 17.2%, respectively. 5. Following fatigue, there were five subjects in whom the large afferents remained blocked and the experimental findings were consistent with the existence of reflex inhibition during fatigue. The mean maximal plantarflexion torque decreased further by 36.2 +/- 7.6% from the value following the compression block compared to a decrease of 5.0 +/- 9.9% in the ischaemia control. The mean EMG associated with these contractions also decreased from post-block values by 56.8 +/19.6% following fatigue and by only 6.4 +/- 8.0% following ischaemia alone. 6. The peripheral excitability of the neuromuscular junction and muscle fibre membrane was adequate following fatigue as evidenced by only modest changes in the M wave (muscle compound action potential). The descending motor drive was deemed sufficient because of the absence of any large interpolated twitches superimposed upon the maximal voluntary contraction in all but two subjects. 7. The declines in maximal plantarflexion torque and the associated EMG activity were very similar to those found in a previous study in which the sensory input was unaltered. The findings demonstrated that any reflex inhibition of the alpha-motoneurone pool during fatigue was probably not mediated by large diameter afferents. Rather, it is suggested that the reflex is mediated by smaller diameter afferents originating from the fatigued muscle.

Cervical Spinal Stenosis
Can Spinal Cord Compression Cause the Fibromyalgia Syndrome?
Dan S. Heffezi M.D., Daniel G. Malone2M.D., Sam R. Bannerl M.D., Alan Shepardl M.D.,
Ruth E. RossI Ph.D. and James W. Robertsoni B.S. (Sponsored by Daniel Malone)1 Chicago
Institute of Neurosurgery and Neuroresearch, Chicago, IL 60614 and 2University of
Wisconsin at Madison, Madison, WI 53706
OBJECTIVE: The symptoms of cervical myelopathy mimic those of fibromyalgia. We
established a prospective database to catalogue neurological findings in patients with
fibromyalgia to examine the possible etiological role of spinal cord compression. The
principal criterion for referral is cervical spinal canal or foramen magnum stenosis on a
screening MRI scan. Patients complete a detailed questionnaire regarding current symptoms
and past medical care and are examined by a neurologist and a neurosurgeon. Measures of
balance, strength, coordination, and cognitive function are obtained using a battery of
standardized tests.
METHODS: To date, forty-five consecutive fibromyalgia patients (87% female, median age
44 years, median duration of illness 6 years) have been evaluated for myelopathy.
Neurological symptoms included fatigue (93%), fatigue upon exertion (98%), cognitive
impairment (96%), diffuse pain (93%), headache (89%), weakness (89%), impaired balance
(80%), paresthesiae (82%), clumsiness (71%), numbness (73%), dizziness (62%), and
diplopia (71 %). Neurological signs included hyperreflexia (80%), spinothalamic sensory level
(79%), recruit of reflexes (44%), impaired tandem walk (32%), positive Romberg sign (31 %),
clonus (28%), Hoffman sign (26%), dysdiadokokinesia (28%), impaired position sense (19%)
and dysmetria (19%). Only 3 patients had a normal neurological examination. Detailed MRI
imaging of the cervical spine and foramen magnum revealed cervical stenosis (n=21),
brainstem compression due to tonsillar ectopia (n=12) or, both cervical stenosis and tonsillar
ectopia (n=11).
CONCLUSION: We conclude that some patients with fibromyalgia have cervical myelopathy
on the basis of spinal cord or cervicomedullary compression. We recommend a thorough
neurological examination and a screening MRI scan of the cervical spine and brain in all
patients with fibromyalgia who do not respond to conventional medical therapy.

Arq Neuropsiquiatr. 2007 Jun;65(2A):256-61.
Diferential diagnosis in atypical facial pain: a clinical study.
Nobrega JC, Siqueira SR, Siqueira IT, Teixeira MJ.
Neurological Division, Hospital das Clinicas, Medical School, University of Sao Paulo, Sao
Paulo, Brazil.
OBJECTIVE: To evaluate a sample of patients with atypical facial pain (AFP) in comparison
to patients with symptomatic facial pain (SFP). METHOD: 41 patients with previous
diagnostic of AFP were submitted to a standardized evaluation protocol, by a
multidisciplinary pain team. RESULTS: 21 (51.2%) were considered AFP and 20 (48.8%)
(SFP) received the following diagnosis: 8 (40.0%) had temporomandibular disorders (TMD);
3 (15.0%) had TMD associated to systemic disease (fibromyalgia, systemic erythematosus
lupus); 4 (20.0%) had neuropathy after ear, nose and throat (ENT) surgery for petroclival
tumor; 2 (10.0%) had Wallenberg syndrome; 1 (5.0%) had intracranial tumor; 1 (5.0%) had
oral cancer (epidermoid carcinoma), and 1 (5.0%) had burning mouth syndrome (BMS)
associated to fibromyalgia. Spontaneous descriptors of pain were not different between AFP
and SFP groups (p=0.82). Allodynia was frequent in SFP (p=0.05) and emotion was the
triggering factor most prevalent in AFP (p=0.06). AFP patients had more traumatic events
previously to pain (p=0.001). CONCLUSION: AFP patients had more: a) traumatic events
previously to pain onset, and b) emotions as a triggering factor for pain. These data support
the need of trained health professionals in multidisciplinary groups for the accurate diagnosis
and treatment ofthese patients.

Acid Reflux: GERD Can Masquerade As Persistent Cough Or Even Chest Pain
Chronic cough may be caused or triggered by gastroesophageal reflux disease (GERD), which
is the third most common cause of chronic unexplained cough after bronchial asthma and
postnasal drip. Many patients with unexplained cough have underlying GERD without the
classic reflux symptoms making clinicians unaware that GERD may be playing a crucial role
in these patients. Aggressive therapy of GERD results in resolution of cough in almost 80 to
95% of patients with GERD associated cough. This short review attempts to describe the
underlying mechanisms, diagnostic evaluation and the current management of GERD related
cough in the general practice.
1. Irwin RS, Corrao WM, Pratter MR. Chronic persistent cough in the adult: the spe

Heartburn, Gastrointestinal Problems, Pain Control, Diseases and Conditions, Heart Disease
Researchers at the Brigham & Women’s Hospital in Boston studied patients in emergency
rooms who complained of serious chest pain. They measured and recorded pH levels in the
esophagus of 31 patients for two days to determine whether excessive acid caused their chest
pain. Researchers found more women than men were being rushed to the emergency room
with chest pain that was not related to the heart.
Abnormal reflux of acid that would fit the diagnosis of GERD was seen in 57 percent of
patients. There are two types of acid reflux, supine, which occurs when the patient is sleeping,
and upright which occurs when the patient is awake. In this study, men had more upright
reflux, while women experienced both reflux during sleep and while they were awake.
According to lead investigator Dr. Julia 1. Liu, “Often the role of acid reflux has been
overlooked as a potential factor in the diagnosis and treatment of patients with serious chest
pain. But, it is important for patients never to assume their chest pain is caused by GERD until
they have been thoroughly evaluated by a physician to rule out heart disease. If they
experience persistent chest pain, they should seek emergency medical care.”
Esophageal Acid Testing
GERD is one of the most common causes of chronic cough. While persistent cough can be
caused by acid reflux, in some cases, the cough could result from the reflux of non-acidic
stomach contents. Researchers at the Medical University of South Carolina in Charleston
studied a group of patients with persistent cough who took acid-suppression therapy (proton
pump inhibitors) over a period of three years to evaluate the cost-effectiveness of Mil-pH, a
device that can detect reflux without depending on the acidity of the contents that refluxes
into the esophagus. Unlike conventional pH monitoring, which measures acidity, this new
technique can detect non-acid reflux.
Researchers used a cost-utility analysis to evaluate the cost-effectiveness of this diagnostic
intervention among patients on high dose PPI therapy with chronic persistent cough who
might be candidates for anti-reflux surgery, such as laparoscopic fundoplication. Researchers
included costs of medication use, physician visits and surgery in their model.
According to Dr. Deepika Koya, “The use of MIl-pH testing in patients who experience reflux
of non-acid stomach contents is cost-effective by helping clinicians determine which patients
would benefit from anti-reflux surgery and excluding those for whom surgery may have no
benefit. This warrants further evaluation of widespread application of MIl-pH testing in the
diagnosis of patients with persistent chronic cough on adequate medical therapy.”
About GERD
GERD is caused by the regurgitation or reflux of gastric fluid into the esophagus. The most
common symptom of GERD is frequent or persistent heartburn two or more times a week.
Other symptoms of GERD include chest pain, coughing, wheezing, difficulty swallowing, and
an acidic or sour aftertaste in the mouth or throat. Each year, GERD accounts for up to 60
percent of patient visits to the emergency room with chest pain not related to the heart,
according to the American College of Emergency Physicians.
If you experience severe abdominal pain or chest discomfort, you should seek immediate,
emergency medical treatment. By seeing your doctor early, the physical cause of GERD can
be treated and more serious problems avoided.

Cross-correlation between stress, pain, physical activity, and temporalis muscle EMG in
tension-type headache
GT ClarkllUCLA School of Dentistry, Section of Diagnostic Sciences and Orofacial Pain,
Los Angeles, CA, USA; ,
S Sakai11UCLA School of Dentistry, Section of Diagnostic Sciences and Orofacial Pain, Los
Angeles, CA, USA; ,
R Merri1111UCLA School of Dentistry, Section of Diagnostic Sciences and Orofacial Pain,
Los Angeles, CA, USA; ,
VF Flack22UCLA School of Public Health, Department of Biostatistics, Los Angeles, CA,
C McCreary33UCLA Neuropsychiatric Institute, Department of Biobehavioral Sciences, Los
Angeles, CA, USA
lUCLA School of Dentistry, Section of Diagnostic Sciences and Orofacial Pain, Los Angeles,
CA, USA; 2UCLA School of Public Health, Department of Biostatistics, Los Angeles, CA,
USA; 3UCLA Neuropsychiatric Institute, Department of Biobehavioral Sciences, Los
Angeles, CA, USA
Glenn T Clark, UCLA School of Dentistry, Box 951668, Rm. 43-009 CHS, Los Angeles, CA
90095-1668, USA. Tel. +13108256406, fax. +1310 2065539.
Thirty-six tension-type headache subjects and 36 non-headache matched controls recorded
their temporalis muscle electromyographic (EMG) activity and their pain intensity, stress and
physical activity levels in a daily diary. Measurements were performed every 30 min for 6
days (EMG 3 days only). A time-lagged cross-correlational analysis between pain, stress,
physical activity, and EMG shows that the highest correlation coefficient values occurred
between pain and stress at the same (r=0.33) and at the two preceding 0.5 h time points
(r=0.21 and r=0.26) in the headache group. Virtually no correlation was found between pain,
stress, or physical activity with EMG for either group. These data show that temporalis
muscle activity levels were not related to the rise and fall ofthe subjects’ pain or stress levels.
Conversely, elevated stress appeared to be highly related to pain; it occurs as both an
antecedent and simultaneous event with elevated headache pain.

Neck flexor muscle fatigue in adolescents with headache – An electromyographic study.
BACKGROUND: Muscular disorders of the neck region may be of importance for the
etiology of tension-type headache. However, in adolescents, there are no data on the
association between neck muscle fatigue and headache. AIM: To study differences in fatigue
characteristics of the neck flexor muscles in adolescents with and without headache.
METHODS: A population-based sample of 17-year-old adolescents with migraine-type
headache (N=30), tension-type headache (N=29) and healthy controls without headache
(N=30) was examined. Surface EMG data were recorded from the sternocleidomastoid (SCM)
muscles bilaterally during an isometric neck flexor endurance test. The spectral median
frequency (MF) change during the total endurance time (TMF) and the initial time of 30s
(IMF) was calculated. The intensity of discomfort in the neck area was assessed with the
visual analogue scale (VAS). RESULTS: The rat~ of decline in TMF of both SCM muscles
was significantly increased in the tension-type headache group compared with controls (right
SCM, P=0.030, OR 2.0, 95% 1.2-3.7; left SCM, P=0.009, OR 2.5, 95% 1.4-4.9), while no
significant differences were found between controls and subjects with migraine. The rate of
decline in IMF, the total endurance time (P=0.050), and VAS did not differ significantly
among the study groups. CONCLUSIONS: This preliminary finding shows that increased
neck flexor muscle fatigue in adolescents seems to be associated with tension-type headache.
Authored by Oksanen A, Poyhonen T, Metsahonkala L, Anttila P, Hiekkanen H, Laimi K,
Salminen JJ. Department of Physical and Rehabilitation Medicine, Turku University Central
Hospital, P.O. Box 52, FIN-20521 Turku, Finland.
Published in Eur J Pain. 2007 Feb 7; T
Authored by Shimazaki K, Matsubara N, Hisano M, Soma K. Orthodontic Science,
Department of Orofacial Development and Function, Division of Oral Health Science,
Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo
113-8549, Japan.

Acta Otolaryngol. 2005 Nov;125(l1):1168-75.
Tonic contractions of the tensor tympani muscle: a key to some non-specific middle ear
symptoms? Hypothesis and data from temporal bone experiments.
Pau HW,Punke C, Zehlicke T, Dressler D, Sievert U.
Klinik und Poliklinik fUr Hals-Nasen-Ohrenkrankheiten, Kopf- und Halschirurgie, Rostock,
CONCLUSIONS: The results of this study show that in clinical practice it will not be easy to
diagnose tonic contractions of the tensor tympani muscle and only a combination of findings
will be helpful. Based on these experimental results a clinical study will be started which
should clarify the diagnostic relevance of indicators of tonic tensor muscle contractions.
OBJECTIVES: There are indications from the literature and from personal experience that
tonic contractions of the tensor tympani muscle may play a role in some ear symptoms, such
as fullness, certain cases of tinnitus, slight hearing loss or Meniere’s disease-like fmdings. In
order to prove this theory we looked for indicators, either visual or functional, to help
clinically diagnose the functional state of the muscle, particularly its tonic contraction.
MATERIAL AND METHODS: Experiments simulating tensor contractions were carried out
on temporal bone specimens. Traction was applied either to the isolated muscle, to its tendon
or to the malleus neck. Effects were observed either visually via an endoscope or by
impedance audiometry using multiple-frequency tympanometry. RESULTS: During
simulated tensor traction the aspect of the tympanic membrane changed slightly, i.e. there was
some inward movement of the umbo. However, such effects were only identifiable during the
pulling action or by directly comparing the “contracted” and “relaxed” states. Tympanometry
revealed a decrease in the peak amplitudes and a shift in the middle ear resonance towards
higher frequencies during contractions.

T. S. Tan1, 2 Contact Information, M. Shoeb1, S. Winterl and M. C. Frampton1
(1) Department of Otorhinolaryngology, Head and Neck surgery, Bedford Hospital,
Kempston Road, Bedford, UK
(2) 181 Fishguard Way, London, E16 2RX, UK
Acute sensorineural hearing loss is an uncommon phenomenon. We describe the first case of
a 42-year-old lady who presented with acute sensorineural hearing loss occurring immediately
after a dental procedure. Possible mechanisms are discussed. She was treated with high dose
oral steroids, low molecular weight dextran and vasodilators with benefit.

Rich observed a relationship between the HIP Plane and the occlusal plane which was
confirmed by Karkazis and Polyzois’s cephalometric study:
Rich H: Evaluation and registration of the HIP plane of occlusion, AUST DENT J, 27:162168,
Karkazis, HD & Polyzois, GL: Cephalometrically predicted occlusal plane: Implications in
removable prosthodontics, J Prosth Dent, 65:258-264, 1991
When the patient does not have TMD the odontoid is centred. If one condyle is retruded
relative to the other then the odontoid will not be centred because as shown the atlas and TMJ
condyle work synchronously.. Secondly when the patient who has a displaced odontoid is
TENSED and places the bite in position the odontoid corrects. If the TENS orthotic or bite is
taken out then the odontoid again displaces. The fact that one observes almost 100 percent
odontoid displacement is because they do have TMD if the study includes correcting the HIP
plane first on the ICAt.Most forget to do this and of course the TMJs will then be incorrect in
any position .The definition oftmd is thus a retruded TMJ condyle(s) which is almost always
accompanied by A/O subluxation .One is able to palpate the retruded condyle.Furthermore the
patient’s posture is not correct and their is a scoliotic spine and the subluxed atlas may be
diagnosed by palpation which may be easily taught. . Do a post TENS bite and test for fatigue
.If the odontoid is not corrected then there will still be fatigue on scan 18. The ascending type
will be corrected to non fatigued position so long as the maxillary model is set to HIP and not
some arbitrary Fox Plane position etc.When TENS does not correct AlO then the patient
requires AlO correction by an atlas orthoganist followed by a TENS bite for stability.Yes a
pilot study was undertaken following AlO correction including relief of symptoms ( placebo
)and followed by scan 18.The study was blinded Roy did not know nor did the orthoganist
.Only I was able to know which was control and which was experimental subject. We are in
the process of extending the study but we need funds and hope that NIH will support the
research. I have the records and show them to all Core 1 students.It is also possible to show
the atlas is displaced by palpation. The patient does not need to be held by a head strap.The
important position is for the patient to hold the horizontal gaze.

J Oral Rehabil. 2007 Feb;34(2):136-40.
Three-dimensional analysis of the occlusal plane related to the hamular-incisive-papilla
occlusal plane in young adults.
Fu PS, Hung CC, Hong lM, Wang JC.
Department of Prosthodontics, Graduate Institute of Dental Science, Kaohsiung Medical
University, Kaohsiung, Taiwan.
The planes which serve as references for cranium and face in dental clinical application
included the occlusal plane, Frankfort plane, Camper’s plane and hamular-incisive-papilla
(HIP) plane. The HIP occlusal plane is a horizontal plane passing through the bilateral
hamular notches and the incisive papilla (Dent Surv. 1975;51:60). The aim of this study was
to estimate the relationship between the various occlusal planes and the HIP plane in
Taiwanese young adults with approximately optimal occlusion. Study casts of 100 young
adults (50 men and 50 women) were selected in this study. All market points on the maxillary
casts were measured by a three-dimensional precise measuring device. The angular
relationship between the four various occlusal planes and the HIP plane were investigated.
The vertical distances between the cusp tips and incisal edges of maxillary teeth to the HIP
plane were measured. Data were performed by the Statistic analysis software programme
(JMP 4.02). The Student’s t-test and Pearson’s correlation test were used to test the statistical
significance (P < 0.05). The results showed that the occlusal plane defined as the incisal edge of maxillary central incisor to mesiobuccal cusp tips of maxillary second molars had the smallest included angle with the HIP plane (2.61 +/- 0.81 degrees). The incisal edge of maxillary right central incisal to mesiopalatal cusp tips of maxillary first molars had the largest included angle with the HIP plane (7.72 +/- 1.60 degrees). The curve is drawn through the buccal cusp tips of maxillary teeth had better parallelism with the HlP plane.

Immune system-central nervous system interactions: effect and immunomodulatory
consequences of immune system mediators on the brain.
P HBlack
Department of Microbiology, Boston University School of Medicine, Massachusetts 02118.
A bidirectional circuit exists between the central nervous system and the immune system,
since activation of the immune system results in the elaboration of cytokines and
inflammatory mediators; these mediators induce hypothalamic CRF, which stimulates the
release of the same immunosuppressive molecules that mediate the response to stress. The
brain, therefore, is likely to be involved in immune system regulation. Hypofunctioning of the
HPA axis with insufficient down regulation may be involved in autoimmune or other diseases
with excessive immune system activation. Hyperfunctioning of the HPA axis, which is not
appropriately suppressed, has been found in a large number of patients with major depression.
Evidence that stress is an important factor in both lowering resistance to infectious agents and
contributing to the reactivation of latent viruses is discussed. Also discussed is the evidence
that stress induces proinflammatory cytokines which may contribute to both the pathogenesis
of inflammatory diseases of unknown etiology and the progression of HIV infection to AIDS
by activation ofHIV replication.
Considerable evidence points to an immunoregulatory function for the hypothalamuspituitary-
adrenal (HPA) axis, suggesting that appropriate reactivity of the HPA axis is
necessary to prevent the immune system from reaching a level that may be damaging for the
host. It is further hypothesized that dysfunctional reactivity of the HPA axis may increase the
vulnerability of the organism to immune-related disorders such as inflammatory diseases.

Impact of Gender, Menstrual Cycle Phase, and Oral Contraceptives on the Activity of the
Hypothalamus-Pituitary-Adrenal Axis
Clemens Kirschbaum, PhD, Brigitte M. Kudielka, MS, Jens Gaab, MS, Nicole C. Schommer,
MS and Dirk H. Hellhammer, PhD
From the Center for Psychobiological and Psychosomatic Research, University of Trier,
Address reprint requests to: Clemens Kirschbaum, PhD, Center for Psychobiological and
Psychosomatic Research, University of Trier, Dietrichstr. 10-11, 54290 Trier, Germany. Email:
OBJECTIVE: Results from animal and human studies suggest that disregulations of the
hypothalamus-pituitary-adrenal (HPA) axis are involved in several behavioral, circulatory,
endocrine, and immune disorders with clear-cut gender differences in disease prevalence. The
aim of the present study was to investigate sex-specific HPA response patterns with a focus
on the contribution of gonadal steroids as possible mediators.
METHODS: A total of 81 healthy adults were investigated in the present study. Twenty men,
19 women in the follicular phase of the menstrual cycle, 21 women in the luteal phase, and 21
women using oral contraceptives (OC) were exposed to a brief psychosocial stress test (Trier
Social Stress Test; TSST) and injected with 0.25 mg ACTHl-24 on consecutive days. Basal
HPA activity was investigated by repeatedly measuring cortisol levels immediately after
awakening, as well as in 30-minute intervals from 9:00 AM to 9:00 PM. Additionally,
questionnaires were used to assess psychological state and trait parameters.
RESULTS: Results show that the TSST induced significant increases in ACTH, salivary-free
cortisol, total plasma cortisol, and heart rates, as well as increased wakefulness and reduced
calmness in the total group. Significant group differences emerged for ACTH and salivaryfree
cortisol stress responses: Although men showed higher ACTH responses to the TSST
compared with each of the three groups of women, salivary cortisol responses showed the
following response pattern: Luteal = Men> Follicular = OC. The salivary cortisol responses
to ACTHl-24 showed a similar response pattern: Luteal> Men> Follicular> OC. In
contrast, total blood cortisol levels did not reveal any group difference between sexes or
follicular versus luteal phase in either test. Although a similar salivary-free cortisol increase
after awakening was found in the four groups, the circadian cortisol profile was significantly
different throughout the first 4 hours of sampling. Questionnaire-derived psychological
variables, as measured in the present study, could not explain the observed results.
CONCLUSIONS: We conclude that gender, menstrual cycle phase, and OC use exert
important effects on HPA responsiveness to psychosocial stress in healthy subjects. Although
men seem to have a stronger hypothalamic drive in response to stressful stimulation than
women, differences in salivary-free cortisol levels, at least in part, may be explained by
estradiol-induced changes in corticosteroid-binding protein levels. ACTH and cortisol
secretion is not affected by OC use per se but the amount of bioavailable unbound cortisol
(“free”) is greatly reduced in this group of women after stimulation. Inasmuch as none of
these differences between the study groups emerged in total blood cortisol levels, we strongly
advocate for the simultaneous measurement of free and total cortisol levels in future studies
on HPA function.

Cranio. 2003 Jan;21(l):50-60.
Symptom relief after treatment of temporomandibular and cervical spine disorders in patients
with Meniere’s disease: a three-year follow-up.
Bjorne A, Agerberg G.
Vertigo Tinnitus, and Pain Unit, Ystad Hospital, Public Dental Service, County of Skane,
This study describes the coordinated treatment of temporomandibular disorders (TMD) and
cervical spine disorders in patients diagnosed with Meniere’s disease. The aim was to follow
up treatment outcomes for three years with regular follow-up examinations every six months.
Of the 31 patients with Meniere’s disease who participated in a controlled comparative study
on the signs and symptoms of TMD, 24 participated in a subsequent controlled comparative
study on the signs and symptoms of cervical spine disorders (CSD). These 24 Meniere’s
disease patients (ten males and 14 females) agreed to participate in this longitudinal study. At
each follow-up, their symptoms were evaluated using self-administered questionnaires and
visual analog scales (VAS). The results of the coordinated treatment showed simultaneous
decreases in the intensities of vertigo, nonwhirling dizziness, tinnitus, feeling of fullness in
the ear, pain in the face and jaws, pain in the neck and shoulders, and headache that were both longitudinal and highly significant. Significant longitudinal reductions in the frequencies of
vertigo, nonwhirling dizziness, and headache were also reported by the patients as well as a
complete disappearance of pain located in the vertex area. A significant relief of TMD
symptoms and a decrease in nervousness was also achieved. The results showed that a
coordinated treatment of TMD and CSD in patients with Meniere’s disease is an effective
therapy for symptoms of this disease. The results also suggested that Meniere’s disease has a
clear association with TMD and CSD and that these three ailments appeared to be caused by
the same stress, nervousness, and muscular tension.

Cranio. 1998 Jul;16(3):194-202.
Cervical signs and symptoms in patients with Meniere’s disease: a controlled study.
Bjorne A, Berven A, Agerberg G.
Clinic of Periodontology, Lasarettet, Ystad, Sweden.
This study compares the frequency of signs and symptoms from the cervical spine in 24
patients diagnosed with Meniere’s disease and 24 control subjects from a population sample.
From a previous controlled comparative study concerning signs and symptoms of
craniomandibular disorders, 24 patients diagnosed with Meniere’s disease (10 males and 14
females) and their 24 matched control subjects participated in this investigation on the state of
the cervical spine. Symptoms of cervical spine disorders, such as head and neck/shoulder
pain, were all significantly more frequent in the patient group than in the control group. Most
of the patients (75%) reported a strong association between head neck movements in the
atlanto-occipital and atlanto-axial joints and triggered attacks of vertigo. Also, 29% of the
patients could influence their tinnitus by mandibular movements. Signs of cervical spine
disorders, such as limitations in side-bending and rotation movements, were significantly
more frequent in the patient group than in the control group. Tenderness to palpation of the
transverse processes of the atlas and the axis, the upper and middle trapezius, and the levator
scapulae muscle were also significantly more frequent in the patient group. The study shows a
much higher prevalence of signs and symptoms of cervical spine disorders in patients
diagnosed with Meniere’s disease compared with control subjects from the general population.

Summers, A.O., lWireman, M.l Vimy, F.L. Lorscheider, B. Marshall, S.B. Levy, S. Bennett,
and L. Billard, “Mercury Released form Dental “Silver” Fillings Provokes an Increase in
Mercury- and Antibiotic-Resistant Bacteria in Oral and Intestinal Floras of Primates”,
Antimicrobial Agents and Chemotherapy, (April 1993), pages 825 – 834.
ABSTRACT: In a survey of 640 human subjects, a subgroup of 356 persons without recent
exposure to antibiotics demonstrated that those with a high prevalence of Hg resistance in
their intestinal floras were significantly more likely to also have resistance to two or more
antibiotics. This observation led us to consider the possibility that mercury released from
amalgam (“silver”) dental restorations might be a selective agent for both mercury- and
antibiotic-resistant bacteria in the oral and intestinal floras of primates. Resistances to
mercury and the several antibiotics were examined in the oral and intestinal floras of six adult
monkeys prior the the installation of amalgam fillings, during the time they were in place, and
after replacement of the amalgam fillings with glass ionomer fillings (in four of the monkeys).
The monkeys were fed an antibiotic-free diet, and fecal mercury concentrations were
monitored. There was a statistically significant increase in the incidence of mercury-resistant
bacteria during the 5 weeks following installation of the amalgam fillings and during the 5
weeks immediately following their replacement with glass ionomer fillings. These peaks in
incidence of mercury-resistant bacteria correlated with peaks of Hg elimination (as high as
1mM in the feces) immediately following amalgam placement and immediately after
replacement of the amalgam fillings. Representative mercury-resistant isolates of three
selected bacterial families (oral streptococci, members of the family Enterobacteriaceae, and
enterocaocci) were also resistant to one or more antibiotics, including ampicillin, tetracycline,
streptomycin, kanamycin, and chloramphenicol. While such mercury- and antibiotic-resistant
isolates among the staphylococci, the enterococci, and members of the family
Enterobacteriaceae, have been described, this is the first report of mercury resistance in the
oral streptococci. Many of the enterobacterial strains were able to transfer mercury and
antibiotic resistances together to laboratory bacterial recipients, suggesting that the loci for
these resistances are genetically linked. Our findings indicate that mercury released from
amalgam fillings can cause an enrichment of mercury resistance plasmids in the normal
bacterial floras of primates. Many of these plasmids also carry antibiotic resistance,
implicating the exposure to mercury from dental amalgams in an increased incidence of
multiple antibiotic resistance plasmids in the normal floras of nonmedicated subjects.

Frustaci A, Magnavita N, Chimenti C, Caldarulo M, Sabbioni E, Pietra R, Cellini C, Possati
GF, Maseri A. Department of Cardiology, Catholic University, Rome, Italy. “Marked
elevation of myocardial trace elements in idiopathic dilated cardiomyopathy compared with
secondary cardiac dysfunction.” From: J Am CoIl Cardiol1999 May;33(6):1578-83
OBJECTIVES: We sought to investigate the possible pathogenetic role of myocardial trace
elements (TE) in patients with various forms of cardiac failure.
BACKGROUND: Both myocardial TE accumulation and deficiency have been associated
with the development of heart failure indistinguishable from an idiopathic dilated
cardiomyopathy. METHODS: Myocardial and muscular content of 32 TE has been assessed
in biopsy samples of 13 patients (pts) with clinical, hemodynamic and histologic diagnosis of
idiopathic dilated cardiomyopathy (IDCM), all without past or current exposure to TE. One
muscular and one left ventricular (LV) endomyocardial specimen from each patient, drawn
with metal contamination-free technique, were analyzed by neutron activation analysis and
compared with 1) similar surgical samples from patients with valvular (12 pts)and ischemic
(13 pts) heart disease comparable for age and degree of LV dysfunction; 2) papillary and
skeletal muscle surgical biopsies from 10 pts with mitral stenosis and normal LV function,
and 3) LV endomyocardial biopsies from four normal subjects.
RESULTS: A large increase (>10,000 times for mercury and antimony) of TE concentration
has been observed in myocardial but not in muscular samples in all pts with IDCM. Patients
with secondary cardiac dysfunction had mild increase « or = 5 times) of myocardial TE and
normal muscular TE. In particular, in pts with IDCM mean mercury concentration was 22,000
times (178,400 ng/g vs. 8 ng/g), antimony 12,000 times (19,260 ng/g vs. 1.5 ng/g), gold 11
times (26 ng/g vs. 2.3 ng/g), chromium 13 times (2,300 ng/g vs. 177 ng/g) and cobalt 4 times
(86,5 nglg vs. 20 ng/g) higher than in control subjects.
CONCLUSIONS: A large, significant increase of myocardial TE is present in IDCM but not
in secondary cardiac dysfunction. The increased concentration of TE in pts with IDCM may
adversely affect mitochondrial activity and myocardial metabolism and worsen cellular

The Angle Orthodontist: Vol. 70, No.2, pp. 129-144.
Nonsurgical Rapid Maxillary Expansion in Adults: Report on 47 Cases Using the Haas
Chester S. Handelman, DMD; a Lin Wang, DDS; b Ellen A. BeGole, PhD; c Andrew 1. Haas,
Rapid maxillary expansion (RME) in the adult is thought to be an unreliable procedure with
several adverse side effects and, consequently, surgically assisted RME is considered the
preferred procedure. The purpose of this paper is to study the efficacy of nonsurgical RME,
and to determine the incidence of complications such as relapse of the expansion, pain and
tissue swelling, tipping of the molars, opening rotation of the mandible and gingival
recession. Rapid maxillary expansion using a Haas expander was examined in 47 adults and
47 children. A control group of 52 adult orthodontic patients who did not require RME was
also studied. Students’ t-test, and the analy~is of variance followed by the Scheffe test were
used to determine if there were significant differences among time periods and among the 3
study groups. The mean transarch width increase was similar in adults and children who had
RME; 4.6 ± 2.8 compared to 5.7 ± 2.4 mm for the molars and 5.5 ± 2.4 compared to 5.7 ± 2.5
mm for the second premolars. In the adults, transarch expansion and the correction of the
posterior crossbites were stable following discontinuance of retainers (mean 5.9 years). Ifthe
expander was properly fabricated, and turned no more than once a day, the procedure was
well-tolerated. Rapid maxillary expansion in adults flared the molars buccally only 3° per
side. The mandibular plane and lower facial height were unchanged. The adults achieved 18%
of .their transmolar expansion at the height of the palate and the remainder with buccal
displacement of the alveolus. The children achieved 56% of their expansion by an increase at
the height of the palate with the remainder due to displacement of the alveolus. There was
some buccal attachment loss (0.6 ± 0.5 mm) seen in the female subjects associated with RME,
but the extent was clinically acceptable. This resulted in significantly longer clinical crowns,
but rarely caused exposure of buccal root cementum. Complications were infrequently
observed or of minimal consequence. The results indicate that nonsurgical RME in adults is a
clinically successful and safe method for correcting transverse maxillary arch deficiency.

Multiple Sclerosis And Obstructive Sleep Apnea: Is There A Link?
February 18, 2009
I’m the sleep breathing expert. I answer people’s questions on various topics related to sleep
and breathing. Somehow, I stumbled onto the MS community and was surprised to see that
many people have severe fatigue issues, cold hands and various sleep issues. Their symptoms sounded surprisingly like UARS, which I’ve described before. So I decided to take a poll: I asked three questions:
1. How many MS patients have cold hands or feet?
2. How many MS patients have one or both parents that snore heavily, and if so, what kind of medical problems do they have?
And 3. What’s your favorite sleep position (back, side, or stomach)?
The answers to this informal and unscientific poll was surprisingly lopsided. Out of 36
responses, 31 people said that they had either cold hands or feet. Many had to wear socks
before going to bed, but some had to kick them off later. Fifteen out of sixteen stated that a
parent (usually their father) snored heavily, and many also had major heart disease. Lastly,
26/30 responded that they prefer to sleep on their sides or stomachs. Many complained of
intense fatigue.
This is the exact pattern that I see in patients with upper airway resistance syndrome, where
they also have cold hands or feet, has a parent that snores, and wears mittens and socks to bed.
Typically one or both parents snore, and have various degrees of heart disease. As many
people with UARS slowly gain weight over the years, their cold hands may get better, but
they’ll slowly develop into obstructive sleep apnea.
It’s a given that both UARS and MS will have a physiologic stress response, for different
reasons. This can lead to various autonomic nervous system dysfunctions, such as cold hands
or feet. It’s also known that chronic low-grade physiologic stress can stimulate the immune as
well as the nervous system, heightening both these systems, leading to various pain issues or
autoimmune conditions. I can’t say ifthere’s a definite cause and effect relationship between
UARS and MS, but one thing for sure is that both have problems staying in deep sleep. The
only definitive way to find out is is examine these MS patients with a flexible fiberoptic
camera to examine the airway.
Am I going too far with my sleep-breathing hypothesis, or could I be onto something big?

: Eur J Orthod. 2003 Oct;25(5):457-63.
The effect of occlusal alteration and masticatory imbalance on the cervical spine.
Shimazaki T, Motoyoshi M, Hosoi K, Namura S.
Department of Orthodontics, Nihon University School of Dentistry, Tokyo, Japan.
The characteristics of mandibular lateral displacement include lateral inclination of the
occlusal plane and the differences between the right and left masticatory muscles. The aims of
this investigation were to compare the mandibular stress distribution and displacement of the
cervical spine using three-dimensional finite element models (3D FEM) to simulate
masticatory movements and to clarify the association between morphological and functional
characteristics and head posture. A symmetrical standard model was produced (model-A).
Model-B had higher masticatory muscle strength on the left side, model-C had symmetrical
masticatory muscle strength but the occlusal plane was inclined upwards towards the right and
model-D had the occlusal plane inclined upwards towards the right with higher masticatory
muscle strength on the left side. Model-A showed a completely symmetrical stress
distribution pattern, while in model-B there was an uneven distribution in the mandible with
higher stress on the left side. In addition, the stress distribution in the cervical spine was
asymmetrical, showing displacement to the right. Model-C showed a similar mandibular
tendency to model-B but the opposite tendency in the cervical spine. In model-D, the
mandibular stress distribution was markedly asymmetrical, but almost symmetrical in the
cervical spine with markedly decreased lateral displacement. These results suggest that lateral
inclination of the occlusal plane and imbalance between the right and left masticatory muscles
antagonistically act on displacement of the cervical spine, i.e. the morphological and
functional characteristics in patients with mandibular lateral displacement may play a
compensatory role in posture control.

Journal of Periodontology
2007, Vol. 78, No.4, Pages 764-769
Cementum Crack Formation by Repeated Loading In Vitro
Noriyoshi Noma,* –Hiroshi Kakigawa, Yoshio Kozono, Makoto Yokota*–
*Division of Periodontology, Department of Cariology and Periodontology, Kyushu Dental
College, Kitakyushu, Japan.
tDivision of Biomaterials, Department of Oral Functional Reconstruction, Kyushu Dental
Correspondence: Dr. Makoto Yokota, Science of Oral Functions, Department of Cariology
and Periodontology, Division of Periodontology, Kyushu Dental College, 2-6-1 Manazuru,
Kokurakita-ku, Kitakyushu 803-8580, Japan. Fax: 81-93-581-1003; e-mail: yokota@kyudent.
Background: In this study, the hypothesis was adopted that fatigue destruction may develop
on the cementum of the root surface because of the repeated occlusal stresses loaded on the
tooth as in the case of prolonged occlusal trauma. The purpose of this study is to clarify
whether cemental fatigue destruction occurs when repeated stresses are loaded on the occlusal
surface of a tooth.
Methods: The teeth used were five human mandible premolars from individuals 14 to 22
years of age. The teeth were freshly extracted in orthodontic treatment. They were free of
decay and fillings, and their roots were straight. One half of the root was embedded in cold
curing acrylic resin, and a compressive load of 5.0 kgfwas repeatedly applied along the tooth
axis in water 1 million times with a speed of one time per second. Changes in the tooth
surface were observed by taking photographs with a stereoscopic microscope and a digital
camera after every 100,000 loadings. Cracks were dyed with 2% methylene blue solution, and
crack areas were measured using gray-scaled and binary-processed photographs. Data were
analyzed using image analysis software.
Results: It was confirmed that cracks significantly developed on the buccal, mesial, and distal
surfaces but not on the lingual surface; crack areas showed a tendency to significantly
increase after 500,000 loadings; extension of the crack from the cemento-enamel junction to
the root apex increased with time, and the average extension was 0.67 ± 0.12 mm after 1
million loadings.
Conclusion: This study revealed that cementum cracks developed in the cervix by repeated
loadings and extended toward the root apex with time, suggesting that repeated stresses by
occlusion or strong stresses such as by bruxism may trigger the development of site-specific
attachment loss, which is one of the potential factors inducing periodontal diseases.

Journal Sleep and Breathing
Publisher Springer Berlin / Heidelberg
ISSN 1520-9512 (Print) 1522-1709 (Online)
Category Original Article
DOl 10.1007/s11325-008-0186-6
Correlation between retroglossal airway size and body mass index in OSA and non-OSA
patients using cone beam CT imaging
Yuko Shigetal, 3, Reyes Encis02 Contact
Werner H. Shintakul and Glenn T. ClarkI
Information,Takumi Ogawa3,
(1) Orofacial Pain/Oral Medicine Center, Division of Diagnostic Sciences, School of
Dentistry, University of Southern California, Los Angeles, CA, USA
(2) Division of Craniofacial Sciences and Therapeutics, School of Dentistry, University of
Southern California, 925 West 34th Street DEN 312E, Los Angeles, CA 90089-0641, USA
(3) Department of Fixed Prosthodontic Dentistry, School of Dental Medicine, Tsurumi
University, Yokohama, Japan
Abst~act Most obstructive sleep apnea (OSA) patients are overweight, and OSA is
substantially more common in obese individuals. In morbidly obese patients, at least 70%
suffer from OSA. However, the exact mechanism by which obesity causes OSA is unclear.
The aim of this study is to evaluate the retroglossal airway configuration quantitatively and to
make clear the relationship between Body mass index (BMI) and airway configuration. This
retrospective study included 15 OSA patients (male = 11; female = 4) and 14 normal
controls (male = 8; female = 6). We studied the airway configuration on an axial slice at the
level of the anterior-inferior corner of the second cervical vertebra. Maximum anteriorposterior
diameter (AP) and lateral width (LW) of the airway were measured, and the square
area (SA) was calculated. The airway cross-section area (AWA) was also measured, and then
the AWA/SA ratio was calculated. AP, LW, and AWA were not statistically significantly
different between controls and OSA patients. On the other hand, the AWA/SA ratio in OSA
patients was 8.8% statistically significantly smaller than in controls after adjusting for sex,
age, and BMI. In this sample, there was a negative correlation between age and the AWA/SA
ratio but only in the OSA group. The AWA/SA ratio was significantly negatively correlated
with OSA status (R = -0.5; P = 0.008) after adjusting for BMI and age. In this present
study, we could evaluate the retroglossal airway configuration quantitatively. The AWA/SA
ratio was correlated with OSA status after adjusting for BMI and age.

Svatikova A Wolk R Shamsuzzaman AS Kara TOlson EJ Somers VK
Serum amyloid a in obstructive sleep apnea.
BACKGROUND: Patients with severe obstructive sleep apnea (OSA) may have increased
risk for cardiovascular and cerebrovascular diseases. Serum amyloid A (SAA) protein has
recently been linked to the development of atherosclerosis, stroke, diabetes, and dementia. We
tested the hypothesis that plasma SAA levels are increased in otherwise healthy subjects with
METHODS AND RESULTS: Plasma SAA levels were measured in 10 male patients with
moderate to severe OSA before sleep, after 5 hours of untreated OSA, and in the morning
after effective continuous positive airway pressure treatment. SAA levels were also measured
in 10 closely matched control subjects at similar time points. Baseline plasma SAA levels
before sleep were strikingly higher in patients with moderate to severe OSA than in controls
(18.8+1-2.6 versus 7.2+1-2.6 microg/mL, respectively; P=0.005) and remained unchanged in
both groups throughout the night. SAA levels in 10 male patients with mild OSA were
comparable with controls (P=0.46). Plasma SAA in 7 female patients with moderate to severe
OSA was also markedly higher compared with matched control female subjects (24.1+1-2.4
versus 10.2+1-2.4 microg/mL, respectively; P=0.0013) but was not different from male
patients with moderate to severe OSA (P=0.3). There was a significant positive correlation
between SAA and apnea-hypopnea index (r=0.40, P=0.03).
CONCLUSIONS: Plasma SAA levels are more than 2-fold greater in patients with moderate
to severe OSA compared with subjects with mild OSA or healthy controls regardless of
gender. Elevated SAA may contribute to any increased risk for cardiovascular and neuronal
dysfunction in patients with OSA.

Eur JNeurol. 2006 Feb;13 Suppl1:30-5.
Botulinum toxin therapy of hemifacial spasm: comparing different therapeutic preparations.
Frei K, Truong DD, Dressler D.
The Parkinson’s and Movement Disorders Institute, Fountain Valley, CA 97208, USA.
Hemifacial spasm (HFS) is characterized by involuntary irregular clonic or tonic movements
of the muscles innervated by cranial nerve VII on one side of the face, and is most often a
result of vascular compression of the facial nerve at the root exit zone (Muscle and Nerve
1998;21 :1740). Disability associated with this disorder ranges from social embarrassment to
interference with vision resulting from involuntary eye closure. Treatment of HFS most often
involves botulinum toxin injections, but may also include medications and surgery. We
describe treatment with the three types of botulinum toxin currently commercially available-Botox, Dysport and Myobloc/NeuroBloc.

Am J Epidemiol. 2007 Jan 31
Consumption of Dairy Products and Risk of Parkinson’s Disease.
Chen H, O’reilly E, McCullough ML, Rodriguez C, Schwarzschild MA, Calle EE, Thun MJ,
Ascherio A.
Epidemiology Branch, National Institute of Environmental Health Sciences, Research
Triangle Park, NC.
The authors prospectively investigated the association between intake of dairy products and
risk of Parkinson’s disease among 57,689 men and 73,175 women from the American Cancer
Society’s Cancer Prevention Study II Nutrition Cohort. A total of 250 men and 138 women
with Parkinson’s disease were identified during follow-up (1992-2001). Dairy product
consumption was positively associated with risk of Parkinson’s disease: Compared with the
lowest intake quintile, the corresponding relative risks for quintiles 2-5 were 1.4, 1.4, 1.4, and
1.6 (95 percent confidence interval (CI): 1.1, 2.2; P for trend = 0.05). A higher risk among
dairy product consumers was found in both men and women, although the association in
women appeared nonlinear. Meta-analysis of all prospective studies confirmed a moderately
elevated risk of Parkinson’s disease among persons with high dairy product consumption: For
extreme intake categories, relative risks were 1.6 (95 percent CI: 1.3, 2.0) for both sexes, 1.8
for men (95 percent CI: 1.4, 2.4), and 1.3 for women (95 percent CI: 0.8, 2.1). These data
suggest that dairy consumption may increase the risk of Parkinson’s disease, particularly in
men. More studies are needed to further examine these findings and to explore underlying

Modulation ofH reflex of pretibial and soleus muscles during mastication in humans
Toshiyuki Takahashi, DDS 1 *, Toshiaki Ueno, DDS, PhD 2, Hisashi Taniguchi, DDS, PhD
1, Takashi Ohyama, DDS, PhD 3, Yoshio Nakamura, MD, PhD 4
1Department of Maxillofacial Reconstruction and Function, Division of MaxillofaciallNeck
Reconstruction, Graduate School, Tokyo Medical and Dental University, 5-45 Yushima 1chome,
Bunkyo-ku, Tokyo 113-8549, Japan
2Department of Sports Medicine/Dentistry, Tokyo Medical and Dental University, Tokyo,
3Department of Removable Prosthodontics, Graduate School, Tokyo Medical and Dental
University, Tokyo, Japan
4Department of Welfare and Information, Faculty of Informatics, Teikyo Heisei University,
Chiba, Japan
*Correspondence to Toshiyuki Takahashi, Department of Maxillofacial Reconstruction and
Function, Division of MaxillofaciallNeck Reconstruction, Graduate School, Tokyo Medical
and Dental University, 5-45 Yushima 1-chome, Bunkyo-ku, Tokyo 113-8549, Japan
A previous study in our laboratory demonstrated that the soleus H reflex was facilitated
during mastication in humans. In the present study, we investigated whether there was any
modulation of the magnitude of the pretibial H reflex during mastication in five healthy adult
volunteers. The pretibial H reflex was significantly facilitated during mastication, and there
was no significant difference in the facilitation between jaw-closing and jaw-opening phases;
that is, the gain of the H reflex was modulated tonically but not in a phase-dependent manner
during mastication. Furthermore, in the same subj ects, we confirmed that the soleus H reflex
was facilitated during mastication. Based on our findings, we conclude that the H reflexes in
both the pretibial and soleus muscles undergo a nonreciprocal facilitation during mastication.
It is suggested that mastication contributes to stabilization of postural stance in humans. 2001
John Wiley & Sons, Inc. Muscle Nerve 24: 1142-1148,2001

Improving human ankle joint position sense using an artificial tongue-placed tactile
bio feedback
Nicolas VuillermeCorresponding Author Contact Information, a, E-mail The Corresponding
Author, Olivier Chenua, Jacques Demongeota and Yohan Payana
aLaboratoire TIMC-lMAG, UMR CNRS 5525, La Tronche, France
Proprioception is comprised of sensory input from several sources including muscle spindles,
joint capsule, ligaments and skin. The purpose of the present experiment was to investigate
whether the central nervous system was able to integrate an artificial biofeedback delivered
through electrotactile stimulation of the tongue to improve proprioceptive acuity at the ankle
joint. To address this objective, nine young healthy adults were asked to perform an active
ankle-matching task with and without biofeedback. The underlying principle of the
biofeedback consisted of supplying subjects with supplementary information about the
position of their matching ankle position relative to their reference ankle position through a
tongue-placed tactile output device (Tongue Display Unit). Measures of the overall accuracy
and the variability of the positioning were determined using the absolute error and the
variable error, respectively. Results showed more accurate and more consistent matching
performances with than without biofeedback, as indicated by decreased absolute and variable
errors, respectively. These findings suggested that the central nervous system was able to take
advantage of an artificial tongue-placed tactile biofeedback to improve the position sense at
the ankle joint.

Occlusal patterns in patients with idiopathic scoliosis
BEN-BASSAT Yocheved; YITSCHAKY Michael; KAPLAN Leon; BRIN Ilana;
Introduction: Idiopathic scoliosis is an orthopedic condition characterized by faulty posture. It
might also be associated with some mild forms of facial asymmetry or dental deviations. The
aim of the study was to clinically examine the occlusions of patients with idiopathic scoliosis.
Methods: Ninety-six consecutive orthopedic patients with idiopathic scoliosis were examined.
The orthopedic data of this group were recorded from their hospital files. The occlusal
features of a random group of 705 Ashkenazi children served as the control. Frequency
distributions were compared with the chi-square test. Results: The distribution of the Angle
classes of malocclusion was significantly different in the 2 groups (P = .0001) because of
many Class II subdivision patients in the orthopedic group. Other evidence of asymmetrical
malocclusion was found in upper (P =.002) and lower midline deviations (P =.0001), and a
higher frequency of anterior (P = .024) and posterior (P = .020) crossbites. In the experimental
group, no association was found between site, side, or severity of scoliosis and the appearance or site of the malocclusion features examined. Conclusions: Patients with idiopathic scoliosis have asymmetric features of malocclusion compared with a random population.

Am J Orthod Dentofacial Orthop. 2006 Nov;130(5):629-33.
Occlusal patterns in patients with idiopathic scoliosis.
Ben-Bassat Y, Yitschaky M, Kaplan L, Brin I.
Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine,
Jerusalem, Israel.
INTRODUCTION: Idiopathic scoliosis is an orthopedic condition characterized by faulty
posture. It might also be associated with some mild forms of facial asymmetry or dental
deviations. The aim of the study was to clinically examine the occlusions of patients with
idiopathic scoliosis. METHODS: Ninety-six consecutive orthopedic patients with idiopathic
scoliosis were examined. The orthopedic data of this group were recorded from their hospital
files. The occlusal features of a random group of 705 Ashkenazi children served as the
control. Frequency distributions were compared with the chi-square test. RESULTS: The
distribution of the Angle classes of malocclusion was significantly different in the 2 groups (P
= .0001) because of many Class II subdivision patients in the orthopedic group. Other
evidence of asymmetrical malocclusion was found in upper (P =.002) and lower midline
deviations (P =.0001), and a higher frequency of anterior (P = .024) and posterior (P =.020)
crossbites. In the experimental group, no association was found between site, side, or severity
of scoliosis and the appearance or site of the malocclusion features examined.
CONCLUSIONS: Patients with idiopathic scoliosis have asymmetric features of
malocclusion compared with a random population

1: J Oral Rehabil. 1999 Apr;26(4):280-7.
Awareness/relaxation training and transcutaneous electrical neural stimulation in the
treatment of bruxism.
Treacy K.
Smartrehabilitering Lunds Universitetssjukhus, Lund, Sweden.
Twenty-three bruxists with a short history of dysfunction were randomly assigned to three
treatment groups, MART (Muscular Awareness Relaxation Training), TENS (Transcutaneous
Electrical Neural Stimulation), and a control group. The experimental time was 4 months,
with a total of 20 treatment sessions for each experimental group. The MART group,
decreased their left and right pterygoid-masseter and left and right frontalis electromyographic
(EMG) activity significantly after treatment as compared with the TENS and the control
group. Further, the MART group decreased their number of breaths per minute, increased
their maximum opening of the mouth after treatment to a significantly higher degree as
compared with the TENS and control groups

: Eur J Paediatr Dent. 2008 Dec;9(4):163-9.
Neuromuscular diagnosis in orthodontics: effects of TENS on the sagittal maxillo-mandibular
Monaco A, Cattaneo R, Spadaro A, Marzo G.
Department of Gnatology Clinic. School of Dentistry. University of L’Aquila-Italy.
AIM: This study was conducted in order to assess the changes in the occlusal position of the
mandible after ULF (Ultra Low Frequency)-TENS relaxing procedure in subjects in pubertal
growth phase with diagnosed Angle Class II division 1 and mandibular dentoalveolar
retrusion. MATERIALS AND METHODS: This study was performed on 19 patients (13
females, 6 males) with an Angle Class II division 1, aged between 10 and 15 years old (mean
age 12.26, SD 1.32), characterised by mandible dentoalveolar retrusion and optimal vertical
facial dimension, diagnosed by clinical and cephalometric evaluation. Diagnostic
neuromuscular registrations were made for all subjects. The casts were mounted on articulator
in habitual intercuspal position with a tooth-guided wax bite registration. Reference points
were chosen at molar level. Subsequently the same casts were mounted in myocentric position
and compared to the habitual intercuspal position, assessing the sagittal shift after TENS
procedure. STATISTICS: Mean and standard deviation were calculated on the amount of
shifting at the left molar reference point after TENS procedure. Analysis of variance
(ANOVA), using STATA statistics package, was carried out in order to evaluate the influence
of sex and age on the amount of molar shift. RESULTS: Nine subjects showed, in the sagittal
plane, a forward mandibular shift in neuromuscular myocentric position compared to habitual
intercuspal position. Six subjects showed no differences between habitual and myocentric
position in the sagittal plane. Four individuals showed a backward mandible shift after TENS
indicating worsening of the II molar class in the sagittal plane. (????)CONCLUSION: This
study suggests that TENS recorded occlusion in subjects with Class II division 1 with
mandible dentoalveolar retrusion allows to visualise an unusual trend of growth.
The advancements of the mandible were not taken into account. These results could offer new
diagnosis and prognosis methods for Class II malocclusions.

Prog Brain Res. 2007;166:215-9.
Assessment of temporomandibular and cervical spine disorders in tinnitus patients.
Bjome A.
Vertigo, Tinnitus and Pain Unit, Ystad Hospital, Sturegatan 2A, SE-271 31, Ystad, Sweden.
In treating patients with temporomandibular joint (TMJ) dysfunction it was noticed that
tinnitus and vertigo were common in such patients and there was also muscular tension in jaw
and neck. During treatment of these patients it was also noted that injection of lidocaine in a
jaw muscle (m. pt. lat.) reduced not only their muscular problems but also that the tinnitus
was reduced while the local anesthetic was active. Evaluation of 39 patients with disabling
tinnitus, and all suffered from tinnitus, revealed that 10 of them had bilateral tinnitus and TMJ
disorders revealed that pain in the face, temples or jaw occurred often among these patients.
Many of such patients had also symptoms of cervical spine disorders, head, neck and shoulder
pain, and limitations in side bending and rotation were also frequent complaints. One-third of
these patients could influence tinnitus by jaw movements and 75% could trigger vertigo by
head or neck movements. Treatment of jaw and neck disorders in 24 patients with Meniere’s
disease had a beneficial effect on not only their episodic vertigo but also on their tinnitus and
aural fullness. At the 3-year follow-up, intensity of all symptoms were significantly reduced
(p<O.OOI). Cranio. 1997 Apr;15(2):136-43. The relationship of tinnitus to craniocervical mandibular disorders. Gelb H, Gelb ML, Wagner ML. Department of General Dentistry, Tufts University of College of Dental Medicine, USA. Patients with craniocervical mandibular (TMD) disorders can present with tinnitus as a primary or secondary complaint. The embryology and functional anatomy of the middle ear, temporomandibular joint, muscles of mastication and associated tendons, ligaments, blood vessels, nerves and lymphatics was found to be helpful in establishing etiologic concepts which relate tinnitus to these temporomandibular disorders. In addition to etiologic concepts, treatment modalities are described. The authors relate their experiences as well as those of others with different patient populations.

Headache. 1994 Sep;34(8):471-5.
Is temporomandibular dysfunction a cranial dystonia? An electrophysiological study.
Raudino F.
Neurological Department, Valduce Hospital, Como, Italy.
In 26 patients suffering from temporomandibular dysfunction (TMD) the silent period (ES),
which consists of an early (ES I) and a late (ES2) inhibition which interrupts the voluntary
electromyographic activity after an electrical stimulus, was recorded from the masseter
muscles. Several different patterns were identified: in 8 patients (group I) the ES was normal;
in 1 patient (group II) the ES was entirely absent; in II patients (group III) only the ES2 was
absent and in 6 patients (group IV) ES I and ES2 were combined. Such results can be
explained by hypothesizing several functional states: normal excitability in group I, absolute
(group II) or relative (group III) inexcitability and hyperexcitability in group IV. A central
origin of TMD can be related either to a “dysregulation” of circuits located in the brainstem
which give rise to the ES or to the centers, probably located in the basal ganglia, which
control the circuits of the brainstem.

;”Med Oral Patol Oral Cir Bucal. 2007 Mar 1;12(2):E96-100.
Tensor tympani muscle: strange chewing muscle.
Ramirez LM, Ballesteros LE,Sandoval GP.
Universidad Javeriana, Santa fe de Bogota, Colombia.
This work seeks to alert medical and odontological staff to understanding and using
interdisciplinary handling for detecting different pathologies common otic symptoms. It offers
better tools for this shared symptomatology during therapy s conservative phase. Tensor
tympani muscle physiology and function in the middle ear have been veiled, even when their
dysfunction and anatomical relationships may explain a group of confused otic symptoms
during conventional clinical evaluation. Middle ear muscles share a common embryological
and functional origin with chewing and facial muscles. This article emphasizes that these
muscles share a functional neurological and anatomical dimension with the stomatognathic
system; these muscles increased tonicity ceases to be a phenomenon having no logical
connections. It offers functionality and importance in understanding referred otic symptoms in
common with other extra-otical symptom pathologies. Tinnitus, vertigo, otic fullness
sensation, hyperacusia, hypoacusia and otalgia are not only primary hearing organ symptoms.
They should be redefined and related to the neighboring pathologies which can produce them.
There is a need to understand temporomandibular disorders and craniofacial referred
symptomatology from neurophysiologic and muscle-skeletal angles contained in the
stomatognathic system. Common symptomatology is frequently observed in otic symptoms
and temporomandibular disorders during daily practice; this should be understood by each
discipline from a broad, anatomical and clinical perspective.

Brazilian Oral Research
Print ISSN 1806-8324
VILELLA, Beatriz de Souza, VILELLA, Oswaldo de Vasconcelos and KOCH, Hilton
Augusto. Growth of the nasopharynx and adenoidal development in Brazilian subjects. Braz.
oral res., Jan./Mar. 2006, vol.20, no.l, p.70-75. ISSN 1806-8324.
The purpose of this research was to study the growth of the nasopharynx and adenoid
development. Lateral cephalometric radiographs obtained from 320 white Brazilian subjects
between 4 and 16 years of age were used. All the participants were nose breathers and none of them had previously undergone adenoidectomy. Tracings were made from the radiographs
and cephalometric measurements were performed. The results showed that adenoid sagital
thickness is larger in the age group 4 – 5 years and decreases progressively. There is a slight
increase in the age group 10 – 11 years, but afterwards the decrease continues. However, the
nasopharyngeal free airway space does not decrease in the age group 10 – 11 years, despite the increasing thickness of the adenoid. This is attributable to the downward displacement of the hard palate, resulting in an increase of the free airway space due to growth. Although the
nasopharynx follows a growth pattern similar to that of the rest of the body, adenoid tissue
does not. Adenoidal development seems to differ from that of other lymphatic tissues,
showing a peculiar pattern that can be revealed when hypertrophy due to infections and
allergies is eliminated.

Zhonghua Er Bi Yan Hou Ke Za Zhi. 2004 Nov;39(11):654-7.
Diagnosis and treatment of obstructive sleep apnea hypopnea syndrome in children
Zhang YM, Zhao J, Liu WY,
Department of Otorhinolaryngology, Beijing Children’s Hospital Affiliated Capital University
of Medicine Sciences, Beijing, China.
OBJECTIVE: To discuss the methods of diagnosis and treatment of obstructive sleep apnea
hypopnea syndrome (OSAHS) in children. METHODS: 285 patients diagnosed OSAHS by
X-ray for lateral rhinopharyngeal view, fibrorhinopharyngescopy and overnight
polysomnography ( PSG) were reviewed retrospectively the clinical symptoms and signs. The
patients whose apnea hyponea index(AHI) > or = 5/h, blood oxygen’s saturation reducing over
0.03 are diagnosed as OSAHS. 255/285 cases were performed adenoidectomy andlor
tonsillectomy and 9 cases were treated with continuous positive airway pressure (CPAP).
RESULTS: The major symptoms of patients with OSAHS are snoring in sleep, breathing
opening mouth, apnea, hearing loss. 281/285 cases were diagnosed as adenoid and (or) tonsil hypotrophy. Two hundred- fifty five cases received surgery, adenoidectomy and
tonsillectomy in 205, only adenoidectomy in 47, simple tonsillectomy in 3. The clinical
symptoms of 248 cases improved evidently after operations. Improved rate is 97.2%. In 1-3
months after surgery,PSG were checked in 105 patients again: AHI, the percentage of the
sleep time for saturation monitored by pulse oximetry < 0.90, the longest time of apnea are improved than pre-operation. 9 cases using CPAP received good effects, 7 of 9 cases used CPAP were in pre- and lor post- surgery. Two cases were obesity hypopnea syndrome. CONCLUSIONS: Children with OSAHS has signification themself; PSG is the major means for diagnosing. Surgery is main method for treating; CPAP can be as the method of treating for serious OSAHS in preoperative preparation and postoperative management.

Br Dent 1. 1996 May 25;180(10):382-4.
Mandibular tori, migraine and temporomandibular disorders.
Clifford T, Lamey PJ, Fartash L.
School of Clinical Dentistry, Queen’s University of Belfast.
In this study the presence of mandibular tori was related to conditions associated with
parafunctional activity. Parafunction in the form of tooth clenching or grinding has been
associated with temporomandibular disorders (TMD) and recently migraine. Patients
attending a facial pain clinic in Belfast were assessed for the presence of tori and results
compared to age and gender matched controls. The findings were that mandibular tori were
present significantly more commonly in both migraineurs and TMD patients. The results
support an association with parafunction in the aetiology of mandibular tori and suggest that
tori are a useful marker ofpast or present parafunction in some patients.

Mandibular tori, migraine and temporomandibular disorders.
Br Dent J 1996 May 25;180(10):382-4
Parafunction in the form of tooth clenching or grinding has been associated with
temporomandibular disorders (TMD) and recently migraine. The results support an
association with parafunction in the aetiology of mandibular tori and suggest that tori are a
useful marker of past or present parafunction in some patients.

The Discontinuance of Certain Bodily Movement Disorders by
Reflex Arc Modification.
Anthony B. Sims, DDS, Brendan C. Stack, DDS, MS
Movement disorders such as tic’s and Tourette’s syndrome have been attributed to an
inherited genetic disorder characterized by repeated motor and muscular contractions with no
known origin. This paper will show that Tourette’s syndrome and other movement disorders
are not a physiological or genetic disease but are the result of a mechanosensoritnotor signal
causing a constant irritation and compression of a branch of the auriculotemporal nerve from
the trigeminal nerve at the level of the temporomandibular joint. With the Stack-Sims test and
procedure, a determination of where and how to prevent the continuation of the movement
disorder. There have been multiple research investigations concerning the trigeminal nerve,
it’s anatomy, it’s physiology, and it’s histology. Additionally much research has been done on
the spinal cord, and its nerve pathways throughout the body, especially within the cervical
area. Much has been written about complex regional pain syndrome, nerve compression and
the effects that flow from these movement disorders. Movement disorders have always been
considered a result of disease and or damage that has occurred to the basal ganglia. What is
surprising is that there has been very little written concerning whether or not the trigeminal
nerve or it’s pathway can be associated with any type of movement disorder such as tic’s or
Tourette’s syndrome (or possibly Parkinson’s disease, essential tremors, etc.). The signal
travels from within the temporomandibular joint nerve fibers through the ganglia, down the
spinal cord to the level of C-I and C-2 and it is believed that a reflex pathway occurs within
the dorsal hom motor larnina causing the movement disorders. In addition a signal travels
upward to the thalamus which then goes through the cerebral cortex-corpus striatuni circuitry
(substantia nigra compacta), where it cause’s the depletion of dopaminergic impulses which is
the secondary result ofthe hyperactive nerve.

Neuralgia—inducing cavitational osteonecrosis
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume
86, Issue 1, July 1998, Pages 3-5
Paul D. Freedman, Renee F. Reich and Adam F. Steinlauf
The trigeminal tract and nucleus procedures in treatment of atypical facial pain
Surgical Neurology, Volume 64, Supplement 2, November 2005, Pages S96-S100
Ylicel Kanpolat, Ali Savas, Hasan Caglar Ugur and Melih Bozkurt
Atypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar region, often
radiating to the ear, neck, and shoulders. The pain generally is not within any dermatomal or
anatomical boundaries. Atypical facial pain is distinct from trigeminal neuralgia and its
variants. Therefore, the treatment of AFP should be specified. There is also no consensus in
the treatment of AFP. Two different treatment procedures on the trigeminal tract and nucleus
in a series of cases with AFP are presented.
Between 1989 and 2005, 17 patients with AFP, in whom previous therapies had failed,
underwent computed tomography (CT)-guided percutaneous trigeminal tractotomynucleotomy
(TR-NC). One patient with unfavorable response to TR-NC underwent trigeminal
dorsal root entry zone (DREZ) operation.
In the series with AFP, pain relief was achieved in all of the 17 cases. TR-NC provided
maximum to inadequate degrees of pain relief in 16 of 17 patients. Dorsal root entry zone
operation provided partial relief in 1 case. Neither mortality nor serious permanent
complication was observed in the series.
Neurosurgical procedures such as TR-NC or trigeminal DREZ operation may be effective in
the treatment of intractable AFP. The primary choice of operation should be TR-NC because
this procedure is minimally invasive. Trigeminal DREZ operation, which affects a larger
spread area, may follow if TR-NC fails. The indications and procedure of choice should be
individually tailored, depending on the type of pain, underlying pathology, and experience of
the surgeon.
N Z Dent 1. 2000 Jun;96(424):57.
The great auricular nerve: a case report and review of anatomy.
Tong DC.
Department of Stomatology, School of Dentistry, University of Otago, Dunedin.
This report reviews the pertinent anatomy of the great auricular nerve. The clinical
significance of this nerve is apparent in some patients undergoing lower third molar surgery
under local anaesthesia. The great auricular nerve arises from the cervical plexus and overlaps
territory from the trigeminal nerve supplying sensory innervation to the angle of the mandible.
In certain instances, a separate infiltration may be needed to achieve total analgesia of the

Involvement of the hypothalamic-pituitary-adrenal axis in children with oligoarticular-onset
idiopathic arthritis.
Picco P, Gattorno M, Sormani MP, Vignola S, Buoncompagni A, Battilana N, Pistoia V,
Ravazzolo R.
Ann N Y Acad Sci. 2002 Jun;966:369-72.
Department of Pediatric Rheumatology, G. Gaslini Institute, Genova, Italy.
Adult patients with rheumatic arthritis and other rheumatic disorders show inappropriate
cortisol secretion and peculiar CRR promoter gene polymorphisms. So far, no data are
available about this topic in children with juvenile idiopathic arthritis (JIA). We have studied
a series of 13 prepubertal patients (10 female, 3 male) affected with oligoarticular JIA (o-JIA)
without clinical and biological signs of disease activity (ESR and IL-6). ACTH plasma
concentrations were significantly increased at 8 a.m. in o-JIA patients, whereas no differences
were found in cortisol plasma concentrations. The ACTH/cortisol ratio was significantly
increased in o-JIA patients with respect to the normal population both at 8 a.m. and at noon.
DHEAS and testosterone plasma concentration did not statistically differ in the two
populations. The genetic study was aimed at defining the prevalence of polymorphisms Al
and A2 in o-JIA patients, but we failed to find allelic or genotypic differences. Our study
suggests the presence of a partial resistance to ACTH with a dysregulated pattern of secretion
also in inactive o-JIA patients. These preliminary data need further confirmation in larger
pediatric studies.

Hyposecretion of the adrenal androgen dehydroepiandrosterone sulfate and its relation to
clinical variables in inflammatory arthritis.
Dessein PH, Joffe BI, Stanwix AE, Moomal Z.
Arthritis Res. 2001;3(3):183-8. Epub 2001 Feb 21.
Department of Rheumatology, Johannesburg Hospital, University of the Witwatersrand,
Johannesburg, South Africa.
Hypothalamic-pituitary-adrenal underactivity has been reported in rheumatoid arthritis (RA).
This phenomenon has implications with regard to the pathogenesis and treatment of the
disease. The present study was designed to evaluate the secretion of the adrenal androgen
dehydroepiandrosterone sulfate (DHEAS) and its relation to clinical variables in RA,
spondyloarthropathy (Spa), and undifferentiated inflammatory arthritis (UIA). Eighty-seven
patients (38 with RA, 29 with Spa, and 20 with UIA) were studied, of whom 54 were women.
Only 12 patients (14%) had taken glucocorticoids previously. Age-matched, healthy women
(134) and men (149) served as controls. Fasting blood samples were taken for determination
of the erythrocyte sedimentation rate (ESR), serum DHEAS and insulin, and plasma glucose.
Insulin resistance was estimated by the homeostasis-model assessment (HOMAIR). DHEAS
concentrations were significantly decreased in both women and men with inflammatory
arthritis (IA) (P < 0.001). In 24 patients (28%), DHEAS levels were below the lower extreme ranges found for controls. Multiple intergroup comparisons revealed similarly decreased concentrations in each disease subset in both women and men. After the ESR, previous glucocorticoid usage, current treatment with nonsteroidal anti-inflammatory drugs, duration of disease and HOMAIR were controlled for, the differences in DHEAS levels between patients and controls were markedly attenuated in women (P = 0.050) and were no longer present in men (P = 0.133). We concluded that low DHEAS concentrations are commonly encountered in IA and, in women, this may not be fully explainable by disease-related parameters. The role of hypoadrenalism in the pathophysiology of IA deserves further elucidation. DHEA replacement.

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