Faculty Bibliography

STUDY OBJECTIVES: Temporomandibular pain disorders (TMD) and myofascial pain were linked to increased prevalence of insomnia and obstructive sleep apnea (OSA) on clinical grounds. However, the literature lacks an accurate polysomnographic (PSG) characterization of sleep abnormalities associated with TMD, given that prior studies included small or uncontrolled samples of TMD patients. The present investigation aims to objectively evaluate measures of sleep and respiratory disturbance in a large representative sample of TMD cases in comparison with matched controls. METHODS: Sleep, respiration, and limb movements were measured using a 2-night attended PSG protocol in 170 women-124 TMD cases with myofascial pain and 46 demographically matched controls. The second night data were compared between the groups using ANCOVAs. In TMD cases, the relationship between pain ratings and sleep parameters was analyzed using multiple regressions. RESULTS: In comparison to healthy controls, TMD cased evidenced a significant increase in stage N1 sleep (12.2% +/- 7.6% vs. 9.2% +/- 5.0%, p = 0.03), which was only mild relative to normative values. TMD cases also demonstrated mild but significant elevations in arousals associated with all types of respiratory events (6.0/h +/- 6.1 vs. 3.5/h +/- 3.3 p = 0.02) and in respiratory effort related arousals (RERAs, 4.3/h +/- 4.3 vs. 2.6/h +/- 2.7, p = 0.02). Myofascial pain predicted a lower sleep efficiency (p = 0.01), more frequent awakenings (p = 0.04), and higher RERA index (p = 0.04) among TMD cases. CONCLUSIONS: Myofascial pain in TMD is associated with mild elevation in sleep fragmentation and increased frequency of RERA events. Further research is required to evaluate the clinical significance of these findings. CITATION: Dubrovsky B; Raphael KG; Lavigne GJ; Janal MN; Sirois DA; Wigren PE; Nemelivsky LV; Klausner JJ; Krieger AC. Polysomnographic investigation of sleep and respiratory parameters in women with temporomandibular pain disorders. J Clin Sleep Med 2014;10(2):195-201.

OBJECTIVES: To review the current data for the use of Botulinum toxin type A (BoNT-A) in trigeminal neuralgia (TN) and to describe the preferred injection technique of BoNT-A in TN. To propose a new treatment paradigm for TN incorporating the use BoNT-A. DATA SOURCES: MEDLINE and Google Scholar databases. REVIEW METHODS: The current data on BoNT-A for TN were reviewed and analyzed for outcomes. RESULTS: Seven studies examining the use of BoNT-A were identified: Two randomized double-blind, placebo-controlled studies and five prospective case series. All studies found BoNT-A to be an effective treatment in the majority of patients; and the results of the two randomized double-blind placebo-controlled study showed significant benefit over placebo. The majority of studies used an intradermal or subcutaneous injection technique. The most common side effect was transient facial paresis. CONCLUSIONS: BoNT-A offers a safe, effective, local treatment for TN that is nonablative in nature. BoNT-A should be considered in patients who have failed, become refractory to, or are unable to tolerate first-line pharmacologic treatments. LEVEL OF EVIDENCE: Level 2a Laryngoscope, 2013.

Despite theoretical speculation and strong clinical belief, recent research using laboratory polysomnographic (PSG) recording has provided new evidence that frequency of sleep bruxism (SB) masseter muscle events, including grinding or clenching of the teeth during sleep, is not increased for women with chronic myofascial temporomandibular disorder (TMD). The current case-control study compares a large sample of women suffering from chronic myofascial TMD (n = 124) with a demographically matched control group without TMD (n = 46) on sleep background electromyography (EMG) during a laboratory PSG study. Background EMG activity was measured as EMG root mean square (RMS) from the right masseter muscle after lights out. Sleep background EMG activity was defined as EMG RMS remaining after activity attributable to SB, other orofacial activity, other oromotor activity and movement artefacts were removed. Results indicated that median background EMG during these non-SB event periods was significantly higher (P < 0.01) for women with myofascial TMD (median = 3.31 muV and mean = 4.98 muV) than for control women (median = 2.83 muV and mean = 3.88 muV) with median activity in 72% of cases exceeding control activity. Moreover, for TMD cases, background EMG was positively associated and SB event-related EMG was negatively associated with pain intensity ratings (0-10 numerical scale) on post-sleep waking. These data provide the foundation for a new focus on small, but persistent, elevations in sleep EMG activity over the course of the night as a mechanism of pain induction or maintenance.

PURPOSE: Promoter hypermethylation has been recently proposed as mean for HNSCC detection in salivary rinses. In a prospective study of high-risk population, we showed that EDNRB promoter methylation in salivary rinses is a useful biomarker for oral cancer and premalignancy. EXPERIMENTAL DESIGN: Using that cohort, we evaluated EDNRB methylation status and 8 additional genes. Clinical risk assessment by expert clinicians was performed and compared with biomarker performance in the prediction of premalignant and malignant disease. Methylation status of 9 genes was analyzed in salivary rinses of 191 patients by Quantitative methylation-specific PCR. RESULTS: HOXA9, EDNRB and DCC methylation were associated (p=0.012; p<0.0001; p=0.0005) with premalignant or malignant disease. On multivariable modeling, histological diagnosis was only independently associated with EDNRB (p=0.0003) or DCC (p=0.004) methylation. A subset of patients received clinical risk classification (CRC) by expert clinicians based on lesion examination. CRC, DCC and EDNRB were associated with diagnosis of dysplasia/cancer on univariate (p=0.008; p=0.026; p=0.046) and multivariate analysis (p=0.012; p=0.037; p=0.047). CRC identified dysplasia/cancer with 56% of sensitivity and 66% of specificity with similar AUC (0.61, 95%CI=0.60-0.81) when compared to EDNRB and DCC combined AUC (0.60, 95%CI=0.51-0.69), sensitivity of 46% and specificity of 72%. Combination of EDNRB, DCC and CRC was optimal AUC (0.67, 95%CI=0.58-0.76). CONCLUSION: EDNRB and/or DCC methylation in salivary rinses compares well to examination by an expert clinician in CRC of oral lesions. These salivary biomarkers may be particularly useful in oral premalignancy and malignancy screening in clinical care settings in which expert clinicians are not available.

Aims: To determine whether an intervention reduces oromotor activity and masticatory muscle pain in myofascial temporomandibular disorder (M/TMD) patients with high levels of masticatory muscle activity associated with sleep bruxism. Methods: Fourteen women with M/TMD and prior polysomnographic evidence consistent with sleep bruxism participated in a 10-week single-group pre-test/ post-test mechanistic clinical trial. A 2-week period of baseline monitoring of individually biocalibrated electromyographic (EMG) events associated with sleep bruxism was followed by 6 weeks of EMG-event-contingent treatment via an innocuous electrical pulse to the skin overlying the temporalis muscle. Treatment was discontinued during 2-week follow-up monitoring. Each night before sleep, subjects recorded their average daily pain. Results: Mixed-model analysis of variance showed a reliable reduction of EMG events during contingent stimulation treatment periods, but frequency of EMG events returned to baseline levels during follow-up (linear term, P = .002; quadratic term, P = .001). In contrast, nightly pain reports failed to show any systematic changes during treatment (linear and quadratic trends, both P > .10). Conclusion: Spontaneous pain severity and nighttime oromotor activity vary independently over nights, even in M/TMD patients selected for relatively high levels of both characteristics. J OROFAC PAIN 2013;27:21-31.

BACKGROUND: Many dentists believe that sleep bruxism (SB) is a pathogenic factor in myofascial temporomandibular disorder (TMD), but almost all supportive data rely on patients' self-reports rather than on direct observation. METHODS: The authors administered a structured self-report interview to determine whether a large and well-characterized sample of patients with myofascial TMD (124 women) experienced SB more often than did matched control participants (46 women). The authors then used data from a two-night laboratory-based polysomnographic (PSG) study to determine whether the case participants exhibited more SB than the control participants. RESULTS: The results of independent sample t tests and chi(2) analyses showed that, although self-reported rates of SB were significantly higher in case participants (55.3 percent) than in control participants (15.2 percent), PSG-based measures showed much lower and statistically similar rates of SB in the two groups (9.7 percent and 10.9 percent, respectively). Grinding noises were common in both case participants (59.7 percent) and control participants (78.3 percent). CONCLUSIONS: Most case participants did not exhibit SB, and the common belief that SB is a sufficient explanation for myofascial TMD should be abandoned. CLINICAL IMPLICATIONS: Although other reasons to consider treating SB may exist, misplaced concern about SB's sustaining or exacerbating a chronic myofascial TMD condition should not be used to justify SB treatment.

Our scientific knowledge of bullous pemphigoid (BP) has dramatically progressed in recent years. However, despite the availability of various therapeutic options for the treatment of inflammatory diseases, only a few multicenter controlled trials have helped to define effective therapies in BP. A major obstacle in sharing multicenter-based evidences for therapeutic efforts is the lack of generally accepted definitions for the clinical evaluation of patients with BP. Common terms and end points of BP are needed so that experts in the field can accurately measure and assess disease extent, activity, severity, and therapeutic response, and thus facilitate and advance clinical trials. These recommendations from the International Pemphigoid Committee represent 2 years of collaborative efforts to attain mutually acceptable common definitions for BP and proposes a disease extent score, the BP Disease Area Index. These items should assist in the development of consistent reporting of outcomes in future BP reports and studies

The International Pemphigus Pemphigoid Foundation (IPFF) was founded in 1997. The IPPF lists more than 4500 members. The IPPF provides peer health coaches to aid patients in the navigation of the health care system and recommends dermatologists and other specialists in their area who are experts in autoimmune bullous disease. The IPPF hosts the largest worldwide registry of pemphigus/pemphigoid patients with biospecimen collection opportunities are planned. Twice a year the IPPF hosts formal meetings with invited speakers.