Behnam Aghabeigi’s research on TMJ dysfunction syndrome

According to Behnam Aghabeigi Facial arthromyalgia (FAM) or perhaps the temporomandibular joint pain malfunction symptoms is a type of symptom in which sufferers complain associated with soreness and tenderness in one or perhaps each temporomandibular joints (TMJ), generally with restriction regarding jaw opening. The illness is definitely four times more established in ladies as compared to men in addition to certainly, there are many studies relating these kind of signs and symptoms to damaging life events, stress or deficit of mental support. This disorder can happen separately as well as together with different non-muscular non-joint pain in the face area (atypical facial pain, AFP) or teeth (atypical odontalgia, AO).

They are also regularly associated with idiopathic head, back and neck soreness, cranky intestinal and pruritus. The particular facial discomfort would be better governed together with tricyclic antidepressants even during the absence of depression4 Lately we have now found these particular patients in addition have disadvantaged removal of conjugated tyramine, a organic trait marker observed in endogenous depression5 suggesting a standard metabolic disturbance predisposes to each pain and depression. Nevertheless, the particular underlying biochemical components producing both pain and joint dysfunction continue being proven.

To try to account for the particular joint pain and also dysfunction our interest had been drawn to studies claiming to indicate that psychological pressure as well as pain inside animals had been connected with an improved generation of free radical and by the actual observation that stress activated damage to the actual gastric mucosa was linked to free radical production. ‘,i”

Furthermore according to Dr. behnam aghabeigi Birmingham, there are reports that free radical exercise within synovial fluid through the knee joints of rheumatoid people correlates with the seriousness of the ailment.” A free radical is any chemical as well as atom that contains one or more unpaired electrons making it significantly reactive. The majority of organic substances for example O2 or H,O are nonradicals, comprising simply matched electrons. In addition to triggering agony in animals, in vitro experiments have demostrated that toxins depolymerise hyaluronic acid generating reduce synovial fluid viscosity,” which can impair lube in addition to be responsible for meniscal hesitation along with clicking, as initially suggested by Toller.i3 There has also been proof that free radicals are linked with cartilage damage plus they could motivate bone resorption.

Again, the particular illustration showing the inclusion of eicosanoids in numerous inflamation related joint diseases,” that could be the product of a free radical and or neuropeptide synovitis, might fit their particular known role as one of the crucial mediators of chronic algesia and hyperalgesia.

And now we have analyzed the chance that FAM may, partially, result from the actual inappropriate production of free radicals in inclined folks. Three parameters of free radical generation are measured inside patients showing together with overt symptoms of FAM and/or a history of idiopathic orofacial soreness (AFP and AO):

MATERIALS And Techniques


Three teams of sufferers ended up enrolled just for this research. Systemic free radical activity had been examined inside 1st band of sufferers that were diagnosed as having chronic FAM and/or other idiopathic orofacial discomfort greater than 3-4 months length. Intra-articular free radical activity was researched inside groups II and III which made up sufferers together with unilateral signs of TMJ pain which had been less competent to 12 weeks tricyclic antidepressant therapy as well as were going through TMJ arthroscopy under general anaesthesia. Each of the subjects gave their educated agreement and also none had any other joint disease or known or suspected reputation of sensitivity to aspirin. Ethical approval was acquired for all those treatments.

Group I (systemic free radical activity): 10 pain patients (age range 26-64, mean 41.8 + 11; 9 females, 1 male) and 10 healthful, age and sex-matched volunteers without any prior reputation idiopathic pain were enrolled as controls (age range 29-60, mean 42.129.6). These kind of people in addition to control subjects had 10 ml of venous blood used heparinised tubes and voided their bladders to provide a urine test. Each subject ended up being given an oral dose of 1.2 g of aspirin and after 2 h repeat blood and urine trials had been collected. The particular blood samples were centrifuged quickly and also the plasma along with urine samples kept at – 70°C until assayed for 2,3-DHB.

Group II was comprised of eighteen patients (age range 22-49, mean 33.2+ 8.1; 13 females, 5 males). 2 hours prior to arthroscopy the patients were given 1.2 g of Aspirin orally in order to ensure equilibration between the plasma as well as synovial fluid. At arthroscopy 1 ml of normal saline had been shot into the joint spaces bilaterally, permitted time to mix with the synovial fluid and aspirated through the same needle. Specimens using overt contamination along with blood were discarded. The aspirate quantities had been determined, 50 ul eliminated for haemoglobin assay along with the rest was centrifuged straight prior to the supernatants were stored at -70°C. A venous blood sample was drawn into heparinised tubes simultaneously as the synovial aspirates were collected, centrifuged plus the plasma stored at -70°C until assayed for lipid peroxidation products by TBA assay.

Group III was comprised of 15 sufferers (age range 15-41, mean 28.3 +7.4; 9 females, 6 males). Synovial aspirates were amassed as described above and maintained for hyperalgesic eicosanoid analysis, exclusively prostaglandin E2 (PGE2), leukotriene B, (LTB,) and 15-hydroxyeicosatetraenoic acid ( 15HETE). These subjects did not receive aspirin because of its potential inhibitory effect on eicosanoid production.


Group I

Healthy control subjects along with people presenting with chronic idiopathic orofacial pain didn’t have statistically diverse circulating amounts of the principle 2,5-DHB metabolite of aspirin showing that this metabolic factors governing aspirin clearance weren’t different between the two groups. Even so, the circulating levels of 2,3-DHB, the encouraged product of free radical activity,” was much raised within the soreness clients, although 5 out of 10 of the control subjects were found to have no evident amounts of this kind of compound. The urine concentrations of each metabolites would not vary involving the groups.

Group II

The yield of aspirate varied through 500 ul to 1050 ul, there being absolutely no significant volumetric distinction between the actual symptomatic and symptom free joints. There wasn’t any considerable variation inside the levels of TBA-RS relating to the synovial fluids from the symptomatic and also symptomless joints. Around half of the samples had haemoglobin contamination, however the contribution to the calculated numbers of TBA-RS didn’t significantly affect the analysis of the data. The synovial fluid volume was calculated employing a concentration volume equation depending on the plasma to TMJ aspirate salicylate ratio. This ratio was not tremendously diverse between the symptomatic and symptomless joints, reflecting the absence of virtually any improvement in synovial fluid volume between painful and comfortable joints.

Group III

There wasn’t any mathematical contrast between the levels of 15-HETE in the synovial fluids from symptom free or painful joints.

During the past 10 years, saline aspirates on the upper joint space of the TMJ have been analysed for the existence of a variety of mediators of pathological conditions. Within this research we’ve additionally evaluated saline aspirates, through sufferers showing with a reputation of chronic FAM who were considering arthrostopic assessment, for your possible ways to create, in vivo, free radicals as well as intra-articular eicosanoids. We believe that this method is filled together with difficulties, specifically as the volumetric yield from the number of TMJ aspirate will be varied, inside our situation ranging from 500 ul to 1050 ~1.

An appealing little bit of encouraging facts for your engagement of free radicals in the pathogenesis of FAM is our illustration showing high intra-articular concentrations of the hyperalgesic mediator 15-hydroxyeicosatetraenoic acid ( 15-HETE), whose functionality requires the free radical mediated procedure for lipid peroxidation of arachidonic acid, in synovial fluid. We’ve been not able to illustrate the inclusion of both prostaglandin E2 (PGE,) or leukotriene B4 (LTB,). It can be worth repeating that the eicosanoid levels found by previous investigators are generally artifactually raised even though compared to significant inflammatory illness in other joints. It is of importance that hyperalgesia induced by 15-hydroperoxyeicosatetraenoic acid ( 15-HPETE) in the trial and error animal may drastically lengthen the algesic effect of substance P(SP) producing a chronic pain model not dissimilar to FAM. This isn’t inhibited by nonsteroidal anti-inflammatory analgesics besides dipyrone. Furthermore, a SP antagonist can block this effect.

These bits of information associate with other reports which have identified neuropeptides in the synovial fluid from the TMJ27,28 and each of our observations that have demonstrated that the TMJ capsule is not just richly innervated by SP neuronal tissue, but additionally some other neurogenic peptides which includes calcitonin gene related peptide, neuropeptide Y and vasoactive intestinal polypeptide. Certainly one of the key clinical problems in managing FAM is the inadequate reaction to nonsteroidal anti-inflammatory analgesics, which will associate with the role of hyperalgesic 15-HPETE for being more important as opposed to prostaglandins such as PGE,.

As mentioned by Dr. aghabeigi Birmingham there were simply no substantial distinctions between the symptomatic as well as symptom free joints when it comes to TBA-RS, 15-HETE or synovial fluid volume. Sadly, since it wasn’t morally simple to get saline aspirates from the joints of healthy age and sex-matched pain-free adults, one can possibly just speculate that these levels found represent the pathological procedure. This particular deficiency of difference just isn’t entirely shocking considering that a systemic biochemical disorder will be reflected in both joints in the ends of a single bone. Furthermore, the particular mirror imaging of inflammatory responses in other paired joints within the body which usually lack the one of a kind anatomical and functional qualities of TMJ continues to be caused by neurophysiological impacts. Nonetheless, the presence of potential pain mediators from the symptomless joints also suggests the value of additional circumstances for example local neuropeptide or cytokine release that could be based upon asymmetrical masticatory function along with bruxism, or perhaps personality aspects that influence central modulation of the soreness encounter.

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Management of Apical Bone Loss around a Mandibular Implant a report from Aghabeigi

Proposed etiologic factors include bone overheating, microbial involvement of adjacent teeth, pre-existing bone infection, and overload. However, the mandible and maxilla seem to have different predispositions in response to these causative agents. Treatment protocols for peri-implant infection have included minimally invasive approaches such as granulation tissue removal and detoxification of the implant surface, as well as more aggressive measures.

According to Behnam aghabeigi Birmingham the achievement of osseous healing and reosseointegration in a patient who presented with presented apical bone loss and signs of infection around a mandibular implant. Reosseointegration was achieved following an intraoral apicoectomy-like approach, i. e, removal of the infected nonintegrated portion of the implant, and meticulous debridement of the granulation tissue. A literature review of 13 relevant published studies was conducted. The current understandings regarding the etiology and treatment strategies for management of apical bone loss around dental implants are summarized and presented.

In general, bone loss around an implant has been recognized as a complication that can follow implant treatment.1,2 While the first case in the literature demonstrating isolated apical bone loss was described by McAllister and colleagues3 in 1992, it was Reiser and Nevins in 1995 who first defined bone loss limited to the apical segment of an otherwise osseointegrated implant as an “implant periapical lesion” and further described the rationale for such an occurrence and possible treatment options. Sussman further described periapical implant pathology and proposed 2 patterns of bone loss apical to implants. However, this report was limited to implants placed in partially edentulous jaws adjacent to natural teeth with a history of periapical dental pathology.

While the term “implant periapical lesion” appears often in the literature,6–10 other terms for the same phenomenon such as “apical peri-implantitis,”11 “retrograde peri-implantitis”12–14 “abscess around the apex of an implant”15,16 and “implant demonstrating periapical radiolucencies” have also been identified in Medline searches of the English-language literature.

Reiser and Nevins reported on 10 implant periapical lesions (9 infected and 1 asymptomatic) in a study sample of approximately 3,800 placed implants, suggesting a prevalence of 0.26%. This is the only value for prevalence of implant periapical lesions reported in the literature. Although the incidence of implants with apical bone loss is still unknown, the authors’ literature search found 23 case reports in 13 studies. This suggests that they occur more frequently than initially thought.

Many etiologic factors have been suggested in previous studies. However, the exact mechanism of bone loss in the apical area of an implant is still not well understood. It has not been possible to determine whether related lesions are composed of healthy tissue or created by the destruction of new tissue. It is also possible that such lesions may result from activation of a pre-existing condition. The etiology is likely to be multifactorial.

While observation and monitoring appears to be the preferred management option for small inactive lesions, various treatment modalities have been suggested for infected lesions of larger diameter. Detoxification of the implant surface3,12,13 and/or surgical treatment (an implant apicoectomy-type procedure following an extraoral15 or an intraoral approach and placement of either a bone substitute with membrane coverage 4,9 or autogenous bone chips18 in the bone defect) have been described.

The clinical management of apical bone loss around a mandibular implant using an intraoral apicoectomy-like surgical approach alone is presented. The results of a critical review of the literature on suggested etiologic factors and management options are also presented.

A 56-year-old male patient under went stage-1 implant surgery at the Eastman Dental Hospital (London, UK) for the placement of implants to support an overdenture. Most mandibular teeth had been lost secondary to periodontal disease. The only remaining mandibular teeth were the left second premolar and first molar, which were to be extracted at implant placement. A panoramic radiograph showed no preexisting bone pathology. Two 3.75 18-mm Brånemark Mk III implants (Nobel Biocare, Göteborg, Sweden) were placed in the anterior interforaminal region of the mandible. A nonsubmerged protocol was followed, and two 3-mm healing abutments were connected to the implants before suturing. The patient was advised to keep his mandibular denture out for 2 weeks. The early postoperative period was uneventful.

Standard transmucosal abutments were attached at stage-2 surgery after 4 months. Following a standard prosthetic protocol, a mandibular denture supported by a gold bar with a small distal cantilever was inserted 9 months after implant placement. The unusual delay was caused by the patient’s inability to attend the prosthetic appointments scheduled.

Six months after seating of the mandibular denture, the patient attended an emergency clinic complaining of discomfort around the right implant. He reported the initiation of pain 1 month after placement of the definitive prosthesis. On examination following removal of the gold bar, the right implant was found to be immobile. However, the soft tissues in the apical area appeared erythematous and slightly tender to palpation. The mucosa around the implant neck appeared healthy, and the probing depth was normal. A periapical radiograph showed a small radiolucent area around the apical third of the right implant (Fig 1). Marginal bone loss was stable at the first thread, which is consistent with previous studies on Brånemark System dental implants. Metronidazole was prescribed, and it was decided to explore the periapical lesion with resection of the apical portion of the implant.

The procedure was carried out under local anesthesia. A buccal incision exposed the area in the right mandible. No bone fenestration was found. A bony window was created over the apical area of the implant until the titanium implant could be seen. There was granulation tissue around the apical 4 mm of the implant, which was debrided. Under profuse sterile saline irrigation, the nonintegrated portion of the implant (4 mm) was trimmed using a tungsten carbide fissure bur. Hemostasis was achieved, and the wound was sutured to obtain primary closure. The patient was advised to avoid denture wear for 1 week and was prescribed metronidazole (400 mg 3 times a day for 7 days) and a chlorhexidine gluconate 0.12% mouthwash. No complaints were reported when the patient was examined 1 week later, and the tissues were found to be healing satisfactorily.

The patient was followed for 2 years during which time the implant and the surrounding tissue remained asymptomatic. There were no signs of adverse tissue reaction. There was no tenderness on palpation in the area, and the prosthesis has been stable and has functioned satisfactorily in the postoperative period.

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