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This study assessed the safety and efficacy of three different doses of BoNT-A for persistent myofascial pain (MFP). One hundred female subjects were randomly assigned into five groups (n = 20): oral appliance (OA), saline solution (SS) and three BoNT-A groups with different doses. Pain intensity and pressure pain threshold were evaluated up to 24 weeks after treatment. Adverse effects related to muscle contraction, masticatory performance, muscle thickness and mandibular bone volume were also assessed. Changes over time were compared within and between groups. The “nparLD” package and Wilcoxon signed-rank test were used to analyze the data. BoNT-A reduced pain intensity (p < 0.0001) and increased pressure pain threshold (p < 0.0001) for up to 24 weeks compared to the placebo. No differences were found between BoNT-A and OA at the last follow-up. A transient decline in masticatory performance (p < 0.05) and muscle contraction (p < 0.0001), and a decrease in muscle thickness (p < 0.05) and coronoid and condylar process bone volume (p < 0.05) were found as dose-related adverse effects of BoNT-A. Regardless of the dose, BoNT-A was as effective as OA on MFP. Notwithstanding, due to BoNT-A dose-related adverse effects, we suggest the use of low doses of BoNT-A in MFP patients that do not benefit from conservative treatments.

Background Pain related to temporomandibular disorders (TMD) is a common problem in modern societies. The aim of the article is to present the concepts of TMD pain clinical management. Methods A survey was performed using the PubMed, SCOPUS and CINAHL databases for documents published between 1994 and 2014. The following search keywords were selected using MeSH terms of the National Library of Medicine in combination: TMD pain, TMD, TMJ, TMJ disorders, occlusal splint, TMD physiotherapy, TMJ rheumatoid disorders and TMJ surgery. Original articles and review papers which presented the clinical relevance and practical validity regarding the possibility of application in TMD management have been included. Authors have excluded articles without outstanding practical aspect and evidence-based background. A first selection was carried out by reviewing titles and abstracts of all articles found according to the criteria. After that the full texts of potentially suitable articles were assessed. In line with these criteria, among 11467 results the writers have included 66 papers. Results The most commonly reported conservative treatments are massage therapy and individually fabricated occlusal splints. In addition to massage, other popular methods include manual therapy and taping, warming/cooling of aching joints, and light and laser therapy. Drugs are also commonly used. In the most severe cases of the temporomandibular joint degeneration, surgical restoration of the joint is sometimes applied. Conclusions The authors concluded that conservative treatment including counselling, exercises, occlusal splint therapy, massage, manual therapy and others should be considered as a first choice therapy for TMD pain because of their low risk of side effects. In the case of severe acute pain or chronic pain resulting from serious disorders, inflammation and/or degeneration pharmacotherapy, minimally invasive and invasive procedures should be considered.

The aim of this investigation was to evaluate the effects of local anaesthesia on nerve growth factor (NGF) induced masseter hyperalgesia. Healthy participants randomly received an injection into the right masseter muscle of either isotonic saline (IS) given as a single injection (n = 15) or an injection of NGF (n = 30) followed by a second injection of lidocaine (NGF + lidocaine; n = 15) or IS (NGF + IS; n = 15) in the same muscle 48 h later. Mechanical sensitivity scores of the right and left masseter, referred sensations and jaw pain intensity and jaw function were assessed at baseline, 48 h after the first injection, 5 min after the second injection and 72 h after the first injection. NGF caused significant jaw pain evoked by chewing at 48 and 72 h after the first injection when compared to the IS group, but without significant differences between the NGF + lidocaine and NGF + IS groups. However, the mechanical sensitivity of the right masseter 5 min after the second injection in the NGF + lidocaine group was significantly lower than the second injection in the NGF + IS and was similar to the IS group. There were no significant differences for the referred sensations. Local anaesthetics may provide relevant information regarding the contribution of peripheral mechanisms in the maintenance of persistent musculoskeletal pain.

The aim of this study was to compare the effectiveness of different types of low level laser treatment (LLLT) in reducing pain levels, changing oxygen saturation and bite force in patients with myofacial pain syndrome (MPS). 45 patients were randomly assigned to three groups: Group 1 (GRR laser, n  = 15) received LLLT with Gallium-Aluminium-Arsenide (GaAlAs) diode laser with a wavelength of 904 nm and red laser with a wavelength of 650 nm over masseter muscle region. Group 2 (Nd: YAG laser, n  = 15) were treated with Neodymium-doped Yttrium Aluminium Garnet laser with a wavelength of 1064 nm and the same protocol with Nd: YAG laser was performed in the Group 3 (placebo, n  = 15) using sham device. Pain was evaluated by visual analogue scale (VAS), change in oxygen concentration in the masseter muscle was measured by functional near-infrared spectroscopy- fNIRS and bite force was measured with Flexiforce sensors before and after treatment. There was a significant decrease in VAS scores after treatment in all three groups. When pain scores were compared, a greater reduction was seen in the Group 1 and Group 2. The change in oxygen saturation level was not statistically significant in all three groups ( p  > 0.05). Bite force values showed a significant decrease in treatment groups ( p  < 0.05), while there was no significant change in the placebo group ( p  > 0.05). Nd: YAG and GRR laser treatments were effective in reducing the pain caused by MPS and in reducing bite force values. Clinically, GRR laser system provides more effective results with its regional and practical application. ClinicalTrials.gov ID: NCT06442553.

This fourteen-year retrospective cross-sectional study (August 2010 - July 2024) provides the first analysis of neuropathic craniofacial pain (CFP) in a neurological emergency department (ED), evaluating its types, characteristics, and management. Data from electronic medical records were analyzed using descriptive statistics and non-parametric tests ( p  < 0.05). Among 156 adult CFP patients (median age 61 years; female 108/156, 69.2%), six CFP types were identified, with trigeminal neuralgia (TN) being the most common (122/156, 78.2%), and etiologically defined in 30/122 patients (24.6%). The typical patient was an elderly female with severe, right-sided TN affecting the V2 and V3 branches. Acute treatment lacked guideline-supported rapid-onset options, relying instead on nonopioid and opioid analgesics (48/54 patients, 88.9%). There was a decline in cases after the beginning of the COVID-19 pandemic ( p  = 0.001). Rare CFPs and their combinations can initially present in the ED, where diagnostic complexity and treatment gaps pose significant challenges. These findings highlight the ED’s critical role and the need for institutional guidelines based on ICHD-3 or ICOP to improve CFP management.

Purpose of Review Trigeminal neuralgia (TN) is characterized by recurrent attacks of lancinating facial pain in the dermatomal distribution of the trigeminal nerve. TN is rare, affecting 4 to 13 people per 100,000. Recent Findings Although there remains a debate surrounding the pathogenesis of TN, neurovascular compromise is the most currently accepted theory. Minimal stimulation caused by light touch, talking, or chewing can lead to debilitating pain and incapacitation of the patient. Pain may occur sporadically, though is primarily unilateral in onset. The diagnosis is typically determined clinically. Treatment options include medications, surgery, and complementary approaches. Summary Anti-epileptic and tricyclic antidepressant medications are first-line treatments. Surgical management of patients with TN may be indicated in those who have either failed medical treatment with at least three medications, suffer from intolerable side-effects, or have non-remitting symptoms. Surgical treatment is categorized as either destructive or non-destructive. Deep brain and motor cortex neuro-modulatory stimulation are off label emerging techniques which may offer relief to TN that is otherwise refractory to pharmacological management and surgery. Still, sufficient data has yet to be obtained and more studies are needed.

The Special Issue “Orofacial Pain: Molecular Mechanisms, Diagnosis, and Treatment 2021” contains 6 articles published by 41 authors from different countries focusing on nucleus accumbens core GABAergic neurons, receptor-interacting serine/threonine-protein kinase 1, pannexin 1-mediated ATP signaling, ultra-low-frequency transcutaneous electrical nerve stimulation, and triamcinolone acetonide. The content covers several pain models, including neuropathic pain caused by peripheral nerve constriction or malpositioned dental implants, tongue cancer, myogenous temporomandibular dysfunction, and oral ulcerative mucositis. In addition, a review paper on trigeminal neuralgia is included.

Temporomandibular disorders (TMD) are a group of musculoskeletal diseases affecting masticatory muscles and temporomandibular joints (TMJ). In this context, the chronic TMD could be considered as a condition with chronic primary orofacial pain, presenting as myofascial TMD pain or TMJ arthralgia. In this context, myogenous TMD may present overlapping features with other disorders, such as fibromyalgia and primary headaches, characterized by chronic primary pain related to dysfunction of the central nervous system (CNS), probably through the central sensitization. This phenomenon could be defined as an amplified response of the CNS to sensory stimuli and peripheral nociceptive, characterized by hyperexcitability in the dorsal horn neurons in the spinal cord, which ascend through the spinothalamic tract. The main objectives of the management of TMD patients are: decreasing pain, increasing TMJ function, and reducing the reflex masticatory muscle spasm/pain. The first-line treatments are physical therapy, pharmacological drugs, occlusal splints, laser therapy, extracorporeal shockwave therapy, transcutaneous electrical nerve stimulation, and oxygen–ozone therapy. Although all these therapeutic approaches were shown to have a positive impact on the central sensitization of TMD pain, there is still no agreement on this topic in the scientific literature. Thus, in this comprehensive review, we aimed at evaluating the evidence on pain management and rehabilitation for the central sensitization in TMD patients.

Theta burst stimulation (TBS) is a modified form of high-frequency repetitive transcranial magnetic stimulation (rTMS) with promising effect in chronic pain. The aim of our double-blind, sham-controlled, parallel-group, randomized study was to assess an efficacy of intermittent TBS (iTBS) in the treatment of patients with chronic orofacial pain. Nineteen patients (twelve females) with chronic orofacial pain were prospectively included and randomly assigned to single session of an active (iTBS) or sham (intermediate TBS; imTBS) stimulation delivered to the primary motor cortex (M1) contralateral to painful side. The primary outcome was pain relief assessed using a visual analogue scale (VAS) after stimulation and at the end of two-week follow- up. The secondary outcomes were changes in the quantitative sensory testing (QST). QST set the threshold for thermal and tactile (touch) sensation in the affected facial area. Intermittent TBS, compared with the sham, showed significant improvement in VAS after stimulation, but not at the end of two-week follow-up. Regarding the secondary outcomes (QST), we failed to find any significant difference between iTBS and sham. Our findings demonstrate that iTBS of M1 transiently provides transient and modest subjective pain relief in chronic orofacial pain.

Orofacial pain and tension headache are symptoms that affect a large portion of the population, compromising productivity, social ability, and functional development. The treatment for reducing painful sensation should be chosen carefully, as pharmacological treatment may bring side effects and overload the organism of patients in pain. Low-level laser therapy has been used with local and systemic [vascular] applications for pain control. However, there is still uncertainty in the literature about the ideal dosimetric parameters for photobiomodulation treatment according to patient characteristics. The objective of this project is to validate a dosimetry model based on the relationship between the effects of photobiomodulation with anthropometric and hemodynamic variables, both in local application and systemic application in patients with symptoms of orofacial pain and tension headache. For this purpose, 180 participants with orofacial pain post-covid eligible participants will be randomly assigned to Group 1-Local Photobiomodulation, Group 2-Vascular Photobiomodulation, Group 3-Placebo Local Photobiomodulation, or Group 4-Placebo Vascular Photobiomodulation [Therapy EC-DMC device, São Carlos, Brazil,- 660 nm, 100mW] using stratified block randomization. Before the application, sociodemographic information such as age, skin phototype [classified by the Fitzpatrick scale], weight, height, body mass index [BMI], oxygen saturation [SaO2], blood pressure [BP], heart rate [HR], and thickness of skin, fat, and facial muscles will be collected. During the application, we will collect local temperature, SaO2, BP, and HR. Before and after laser application, blood levels of lactate and hemoglobin, BP, and HR will be measured in the first and last session. In addition to demographic, anthropometric, and hemodynamic variables, the penetrated energy will be quantified using a power meter, and information from orofacial pain and headache symptom questionnaires will be analyzed. The Monte Carlo simulation technique will be used to systematically study the relationship between the light penetration profile into the target tissues and the most relevant variables, namely BMI, tissue layer thicknesses, and skin phototype. Light transmittance, measured in vivo and simulated, will be compared to validate a personalized dosimetry model. The results of this study contribute to validating a Monte Carlo Simulation model to calculate the appropriate dosimetry for photobiomodulation therapies in the control of patients with Post-Covid-19 orofacial pain. Trial registration number: NCT06065969.