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(Created page with "alt=|left|200x200px Few studies have attempted to characterize the pain associated with bruxism (i.e., to examine the neurobiological and physiological characteristics of the mandibular muscles). Some clinical cases and small-scale studies suggest that certain drugs linked to the dopaminergic, serotoninergic, and adrenergic systems can either suppress or exacerbate bruxism. Further, the majority of these pharmacological studies indicate that vari...")
 
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[[File:Bruxer SP2 .jpg|alt=|left|200x200px]]
[[File:Bruxer SP2.jpg|left|200x200px]]  
Few studies have attempted to characterize the pain associated with bruxism (i.e., to examine the neurobiological and physiological characteristics of the mandibular muscles). Some clinical cases and small-scale studies suggest that certain drugs linked to the dopaminergic, serotoninergic, and adrenergic systems can either suppress or exacerbate bruxism. Further, the majority of these pharmacological studies indicate that various classes of drugs can influence the muscular activity related to bruxism, without exerting any effect on OP. Therefore, the sensitization of the trigeminal nociceptive system and the facilitating effect on mandibular stretch reflexes and CNS hyperexcitability are neurophysiopathogenetic phenomena that can be correlated to pain in the craniofacial region. However, up to now, no correlation has been reported between OP, dysfunction of the mesencephalic nuclei, and facilitation of trigeminal nociception, except for a clinical study on a patient affected by pontine cavernoma, which highlighted a relative facilitation of the trigeminal nociceptive system through the blink reflex.


Come anticipato riprenderemo lo stesso linguaggio diagnostico presentato per la paziente Mary Poppins perché divenga un modello assimilabile e praticabile, e cercheremo di sovrapporlo al presente caso clinico denominato 'Bruxer'. The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral OP prevalent in the temporoparietal regions, with greater intensity and frequency on the left side. Neurological examination showed a contraction of the masseter muscles with pronounced stiffness of the jaw, diplopia and loss of visual acuity in the left eye, left gaze nystagmus with a rotary component, papillae with blurred borders and positive bilateral Babynski’s, and polykinetic tendon reflexes in all four limbs.
Few studies have attempted to characterize the pain associated with bruxism (i.e., to examine the neurobiological and physiological characteristics of the mandibular muscles). Some clinical cases and small-scale studies suggest that certain drugs linked to the dopaminergic, serotoninergic, and adrenergic systems can either suppress or exacerbate bruxism. Further, the majority of these pharmacological studies indicate that various classes of drugs can influence the muscular activity related to bruxism, without exerting any effect on OP. Therefore, the sensitization of the trigeminal nociceptive system and the facilitating effect on mandibular stretch reflexes and CNS hyperexcitability are neurophysiopathogenetic phenomena that can be correlated to pain in the craniofacial region. However, up to now, no correlation has been reported between OP, dysfunction of the mesencephalic nuclei, and facilitation of trigeminal nociception, except for a clinical study on a patient affected by pontine cavernoma, which highlighted a relative facilitation of the trigeminal nociceptive system through the blink reflex.


=== Introduzione ===
As anticipated we will take up the same diagnostic language presented for the patient Mary Poppins so that it becomes an assimilable and practicable model, and we will try to superimpose it on the present clinical case called 'Bruxer'. The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral OP prevalent in the temporoparietal regions, with greater intensity and frequency on the left side. Neurological examination showed a contraction of the masseter muscles with pronounced stiffness of the jaw, diplopia and loss of visual acuity in the left eye, left gaze nystagmus with a rotary component, papillae with blurred borders and positive bilateral Babynski's, and polykinetic tendon reflexes in all four limbs.
https://pubmed.ncbi.nlm.nih.gov/24165294/


Come anticipato nel capitolo '[[Bruxism]]' eviteremo di indicare questo disturbo come esclusivo correlato odontoiatrico e cercheremo una descrizione più ampia ed essenzialmente più neurofisiologica facendo un breve excursus sui fenomeno distonici, sullo 'Orofacial Pain' e solo dopo considereremo il fenomeno 'bruxismo' vero e proprio. Successivamente si passerà alla presentazione del caso clinico. [[File:IMG0103.jpg|thumb|300x300px|'''Figura 1:''' The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral Oorofacial pain  ]]Dystonia is an involuntary, repetitive, sustained (tonic), or spasmodic (rapid or clonic) muscle contraction. The spectrum of dystonias can involve various regions of the body. Of interest to oral and maxillofacial surgeons are the cranial-cervical dystonias, in particular, orofacial dystonia (OFD). OFD is an involuntary, sustained contraction of the periorbital, facial, oromandibular, pharyngeal, laryngeal, or cervical muscles.<ref>Thompson PD, Obeso JA, Delgado G, Gallego J, Marsden CD. Focal dystonia of the jaw and differential diagnosis of unilateral jaw and masticatory spasm. J Neurol Neurosurg Psychiatry. 1986;49:651–656. doi: 10.1136/jnnp.49.6.651. [PMC free article][PubMed] [CrossRef] [Google Scholar][Ref list]</ref> OFD can involve the masticatory, lower facial, and tongue muscles, which may result in trismus, bruxism, involuntary jaw opening or closure, and involuntary tongue movement.
 
=== Introduction ===
https://pubmed.ncbi.nlm.nih.gov/24165294/   
 
As anticipated in the chapter '[[Bruxism - en|Bruxism]]' we will avoid indicating this disorder as an exclusive dental correlate and will seek a broader and essentially more neurophysiological description by making a brief excursus on dystonic phenomena, on 'Orofacial Pain' and only then will we consider the phenomenon 'bruxism' true and own. Subsequently we will move on to the presentation of the clinical case.  
 
  [[File:IMG0103.jpg|thumb|300x300px|'''Figura 1:''' The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral Oorofacial pain  ]]Dystonia is an involuntary, repetitive, sustained (tonic), or spasmodic (rapid or clonic) muscle contraction. The spectrum of dystonias can involve various regions of the body. Of interest to oral and maxillofacial surgeons are the cranial-cervical dystonias, in particular, orofacial dystonia (OFD). OFD is an involuntary, sustained contraction of the periorbital, facial, oromandibular, pharyngeal, laryngeal, or cervical muscles.<ref>Thompson PD, Obeso JA, Delgado G, Gallego J, Marsden CD. Focal dystonia of the jaw and differential diagnosis of unilateral jaw and masticatory spasm. J Neurol Neurosurg Psychiatry. 1986;49:651–656. doi: 10.1136/jnnp.49.6.651. [PMC free article][PubMed] [CrossRef] [Google Scholar][Ref list]</ref> OFD can involve the masticatory, lower facial, and tongue muscles, which may result in trismus, bruxism, involuntary jaw opening or closure, and involuntary tongue movement.


The etiology of OFD is varied and includes genetic predisposition, injury to the central nervous system (CNS), peripheral trauma, medications, metabolic or toxic states, and neurodegenerative disease. However, in the majority of patients, no specific cause can be identified. An association was found among painful temporomandibular disorders (TMDs), migraine, tension-type headache, and sleep bruxism, although the association was only significant for chronic migraine. The association between painful TMDs and sleep bruxism significantly increased the risk for chronic migraine, followed by episodic migraine and episodic tension-type headache.<ref>Fernandes G, Franco AL, Gonçalves DA, Speciali JG, Bigal ME, Camparis CM. Temporomandibular disorders, sleep bruxism, and primary headaches are mutually associated. J Orofac Pain. 2013;27(1):14–20. [PubMed] [Google Scholar] [Ref list]</ref>
The etiology of OFD is varied and includes genetic predisposition, injury to the central nervous system (CNS), peripheral trauma, medications, metabolic or toxic states, and neurodegenerative disease. However, in the majority of patients, no specific cause can be identified. An association was found among painful temporomandibular disorders (TMDs), migraine, tension-type headache, and sleep bruxism, although the association was only significant for chronic migraine. The association between painful TMDs and sleep bruxism significantly increased the risk for chronic migraine, followed by episodic migraine and episodic tension-type headache.<ref>Fernandes G, Franco AL, Gonçalves DA, Speciali JG, Bigal ME, Camparis CM. Temporomandibular disorders, sleep bruxism, and primary headaches are mutually associated. J Orofac Pain. 2013;27(1):14–20. [PubMed] [Google Scholar] [Ref list]</ref>
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Orofacial pain (OP), including pain from TMDs, exerts a modulatory effect on mandibular stretch reflexes.<ref>Dubner R, Ren K. Brainstem mechanisms of persistent pain following injury. J Orofac Pain. 2004;18(4):299–305. [PubMed] [Google Scholar] [Ref list]</ref> Electrophysiological studies have shown that experimentally induced pain from injections of 5% hypertonic saline solution into the masseter muscle causes an increase in the peak-to-peak amplitude of the jaw jerk. This facilitatory effect appears to be related to an increased sensitivity of the fusimotor system, which at the same time causes muscle stiffness.<ref>Wang K, Svensson P, Arendt-Nielsen L. Modulation of exteroceptive suppression periods in human jaw-closing muscles by local and remote experimental muscle pain. Pain. 1999;82(3):253–262. doi: 10.1016/S0304-3959(99)00058-5.[PubMed] [CrossRef] [Google Scholar][Ref list]</ref> In addition, a number of animal studies of experimentally-induced muscle pain have shown that activation of the muscle nociceptors markedly influences the proprioceptive properties of the muscle spindles through a central neural pathway,<ref>Ro JY, Capra NF. Modulation of jaw muscle spindle afferent activity following intramuscular injections with hypertonic saline. Pain. 2001;92(1–2):117–127.[PubMed] [Google Scholar] [Ref list]</ref> and that washing of the local algogenic substance causes a return to normal tendon reflexes.
Orofacial pain (OP), including pain from TMDs, exerts a modulatory effect on mandibular stretch reflexes.<ref>Dubner R, Ren K. Brainstem mechanisms of persistent pain following injury. J Orofac Pain. 2004;18(4):299–305. [PubMed] [Google Scholar] [Ref list]</ref> Electrophysiological studies have shown that experimentally induced pain from injections of 5% hypertonic saline solution into the masseter muscle causes an increase in the peak-to-peak amplitude of the jaw jerk. This facilitatory effect appears to be related to an increased sensitivity of the fusimotor system, which at the same time causes muscle stiffness.<ref>Wang K, Svensson P, Arendt-Nielsen L. Modulation of exteroceptive suppression periods in human jaw-closing muscles by local and remote experimental muscle pain. Pain. 1999;82(3):253–262. doi: 10.1016/S0304-3959(99)00058-5.[PubMed] [CrossRef] [Google Scholar][Ref list]</ref> In addition, a number of animal studies of experimentally-induced muscle pain have shown that activation of the muscle nociceptors markedly influences the proprioceptive properties of the muscle spindles through a central neural pathway,<ref>Ro JY, Capra NF. Modulation of jaw muscle spindle afferent activity following intramuscular injections with hypertonic saline. Pain. 2001;92(1–2):117–127.[PubMed] [Google Scholar] [Ref list]</ref> and that washing of the local algogenic substance causes a return to normal tendon reflexes.


However, few studies have attempted to characterize the pain associated with bruxism (i.e., to examine the neurobiological and physiological characteristics of the mandibular muscles). Some clinical cases and small-scale studies suggest that certain drugs linked to the dopaminergic, serotoninergic, and adrenergic systems can either suppress or exacerbate bruxism. Further, the majority of these pharmacological studies indicate that various classes of drugs can influence the muscular activity related to bruxism, without exerting any effect on OP.<ref>Winocur E, Gavish A, Voikovitch M, Emodi-Perlman A, Eli I. Drugs and bruxism: a critical review. J Orofac Pain. 2003;17(2):99–111. [PubMed] [Google Scholar] [Ref list]</ref>
However, few studies have attempted to characterize the pain associated with bruxism (i.e., to examine the neurobiological and physiological characteristics of the mandibular muscles). Some clinical cases and small-scale studies suggest that certain drugs linked to the dopaminergic, serotoninergic, and adrenergic systems can either suppress or exacerbate bruxism. Further, the majority of these pharmacological studies indicate that various classes of drugs can influence the muscular activity related to bruxism, without exerting any effect on OP.<ref>Winocur E, Gavish A, Voikovitch M, Emodi-Perlman A, Eli I. Drugs and bruxism: a critical review. J Orofac Pain. 2003;17(2):99–111. [PubMed] [Google Scholar] [Ref list]</ref>
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==== Case report ====
==== Case report ====
Come anticipato riprenderemo lo stesso linguaggio diagnostico presentato per la paziente Mary Poppins perché divenga un modello assimilabile e praticabile, e cercheremo di sovrapporlo al presente caso clinico denominato 'Bruxer'.<blockquote>The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral OP prevalent in the temporoparietal regions, with greater intensity and frequency on the left side. Neurological examination showed a contraction of the masseter muscles with pronounced stiffness of the jaw, diplopia and loss of visual acuity in the left eye, left gaze nystagmus with a rotary component, papillae with blurred borders and positive bilateral Babynski’s, and polykinetic tendon reflexes in all four limbs.</blockquote>Da ciò che è stato esposto nei capitoli precedenti dallo '[[Introduction]]' ai capitoli ' [[Logic of medic language]]' ed il ultimo il capitolo '[[Bruxism - en|Bruxism]]' oltre alla complessità degli argomenti ed alla vaghezza del linguaggio verbale potremmo trovati di fronte ad un situazione clinica in cui sembra dominare uno dei contesti considerati.   
As anticipated we will take up the same diagnostic language presented for the patient Mary Poppins so that it becomes an assimilable and practicable model, and we will try to superimpose it on the present clinical case called 'Bruxer'.<blockquote>The subject was a 32-year-old man suffering from pronounced nocturnal and diurnal bruxism and chronic bilateral OP prevalent in the temporoparietal regions, with greater intensity and frequency on the left side. Neurological examination showed a contraction of the masseter muscles with pronounced stiffness of the jaw, diplopia and loss of visual acuity in the left eye, left gaze nystagmus with a rotary component, papillae with blurred borders and positive bilateral Babynski’s, and polykinetic tendon reflexes in all four limbs.</blockquote>
{{Q2|does the tennis match start again?|sembrerebbe all'apparenza ma......}}
 
A differenza del paziente con 'Spasmo Masticatorio', il caso clinico del nostro povero 'Bruxer' mostra un fenomeno di sovrapposizione di proposizioni, asserzioni e frasi logiche nel contesto odontoiatrico e neurologico ed all'apparenza nessuno dei due ottiene una assoluta e netta compatibilità e coerenza. Ciò si ripercuote nella clinica in cui tutti gli attori coinvolti ( medici esaminatori) hanno ragione e contestualmente torto rendendo la conclusione diagnostica inadeguata e pericolosa, ma vediamo step by step il processo nel suo insieme.   
From what has been exposed in the previous chapters from the '[[Introduction/en|Introduction]]' to the chapters '[[Logic of medical language: Introduction to quantum-like probability in the masticatory system - en|Logic of medical language]]' and the last chapter '[[Bruxism - en|Bruxism]]', in addition to the complexity of the arguments and the vagueness of the verbal language, we could find ourselves faced with a clinical situation in which seems to dominate one of the contexts considered.   
   
{{Q2|does the tennis match start again?|it looks like it but....}}
 
Unlike the patient with 'Hemimasticatory Spasm', the clinical case of our poor 'Bruxer' shows a phenomenon of overlapping of propositions, assertions and logical sentences in the dental and neurological context and apparently neither of the two obtains an absolute and clear compatibility and consistency. This has repercussions in the clinic in which all the actors involved (medical examiners) are right and contextually wrong, making the diagnostic conclusion inadequate and dangerous, but let's see the process as a whole step by step.   
    
    
==== Significatività dei contesti ====
==== Significance of contexts ====
Nel il '''contesto odontoiatrico''' avremo le seguenti frasi ed asserzioni a cui diamo un valore numerico per facilitare la trattazione e cioè <math>\delta_n=[0|1]</math> dove lo <math>\delta_n=0</math> indica 'normalità' e <math>\delta_n=1</math> 'anormalità e dunque positività del referto:
Nel il '''contesto odontoiatrico''' avremo le seguenti frasi ed asserzioni a cui diamo un valore numerico per facilitare la trattazione e cioè <math>\delta_n=[0|1]</math> dove lo <math>\delta_n=0</math> indica 'normalità' e <math>\delta_n=1</math> 'anormalità e dunque positività del referto:


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<math>\delta_4</math>Symmetric EMG interference pattern in Figure 5, <math>\delta_4 =0\longrightarrow</math> Normalità, negatività del referto
<math>\delta_4</math>Symmetric EMG interference pattern in Figure 5, <math>\delta_4 =0\longrightarrow</math> Normalità, negatività del referto


<center><gallery widths="130" heights="200" perrow="5" slideshow""="" mode="slideshow">
 
File:SC-05-0011.jpg|'''Figura 2:''' <math>\delta_1=0\longrightarrow</math> Le immagini MR dell'articolazione temporomandibolare ( mostrato per semplificazione solo il lato destro) non mostra segni di deragliamento meniscale e/o di infiammazioni. Referto di conseguenza negativo.
 
File:SC-05-0021.jpg|'''Figura 3:''' <math>\delta_2=0\longrightarrow</math>Tracciato assiografico eseguito con cucchiaio paraocclusale che mostra un normale andamento traslatorio e mediotrusivo del condilo destro. Referto di conseguenza negativo
 
File:SC-05-0020.jpg|'''Figura 4:''' <math>\delta_3=0\longrightarrow</math> Tracciato assiografico eseguito con cucchiaio paraocclusale che mostra un normale andamento traslatorio e mediotrusivo del condilo sinistro
In the '''dental context''' we will have the following sentences and statements to which we give a numerical value to facilitate the treatment, namely <math>\delta_n=[0|1]</math> where it <math>\delta_n=0</math> indicates 'normal' e <math>\delta_n=1</math> abnormality and therefore positivity of the report:
File:Bruxer EMG.jpg|'''Figura 4:''' <math>\delta_4=0\longrightarrow</math>Tracciato EMG muscoli masseteri ( superiore/ massetere destro e sinistro rispettivamente). Il test mostra simmetria bilaterale nel reclutamento unità motorie  
 
<math>\delta_1</math> Negative MR report of the TMJ in Figure 2, <math>\delta_1=0\longrightarrow</math>Normality, negativity of the report
 
<math>\delta_2</math> Negative axiographic report for right condylar traces in Figure 3, <math>\delta_2=0\longrightarrow</math> Normality, negativity of the report
 
<math>\delta_3</math> Negative axiographic report for left condylar traces in Figure 4, <math>\delta_3=0\longrightarrow</math> Normality, negativity of the report
 
<math>\delta_4</math> Symmetric EMG interference pattern in Figure 5, <math>\delta_4 =0\longrightarrow</math> Normality, negativity of the report<center><gallery widths="130" heights="200" perrow="5" slideshow""="" mode="slideshow">
File:SC-05-0011.jpeg|'''Figura 2:''' <math>\delta_1=0\longrightarrow</math> Le immagini MR dell'articolazione temporomandibolare ( mostrato per semplificazione solo il lato destro) non mostra segni di deragliamento meniscale e/o di infiammazioni. Referto di conseguenza negativo.
File:SC-05-0021.jpeg|'''Figura 3:''' <math>\delta_2=0\longrightarrow</math>Tracciato assiografico eseguito con cucchiaio paraocclusale che mostra un normale andamento traslatorio e mediotrusivo del condilo destro. Referto di conseguenza negativo
File:SC-05-0020.jpeg|'''Figura 4:''' <math>\delta_3=0\longrightarrow</math> Tracciato assiografico eseguito con cucchiaio paraocclusale che mostra un normale andamento traslatorio e mediotrusivo del condilo sinistro
File:Bruxer EMG.jpeg|'''Figura 4:''' <math>\delta_4=0\longrightarrow</math>Tracciato EMG muscoli masseteri ( superiore/ massetere destro e sinistro rispettivamente). Il test mostra simmetria bilaterale nel reclutamento unità motorie
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<center><gallery widths="250" heights="200" perrow="3" slideshow""="" mode="slideshow">
<center><gallery widths="250" heights="200" perrow="3" slideshow""="" mode="slideshow">
File:Bruxer MEP.jpg|'''Figura 5:''' <math>{\gamma _{1}}=</math> Potenziali Evocati Motori delle radici trigeminali
File:Bruxer MEP.jpeg|'''Figura 5:''' <math>{\gamma _{1}}=</math> Potenziali Evocati Motori delle radici trigeminali
File:Bruxer Jaw jerk.jpg|'''Figure 6:''' <math>{\gamma _{2}}=</math> Jaw jerk rilevato elettrofisiologicamente sui masseteri destro (tracce superiori) e sinistro (tracce inferiori). La morfologia e durata dei periodi silenti denominati 'Esteroceptive Suppression' risultano essere simmetrici.
File:Bruxer Jaw jerk.jpeg|'''Figure 6:''' <math>{\gamma _{2}}=</math> Jaw jerk rilevato elettrofisiologicamente sui masseteri destro (tracce superiori) e sinistro (tracce inferiori). La morfologia e durata dei periodi silenti denominati 'Esteroceptive Suppression' risultano essere simmetrici.
File:Bruxer SP2 .jpg|'''Figure 7:''' <math>\gamma _3=</math> Periodo silente meccanico rilevato elettrofisiologicamente sui masseteri di destra (tracce sovrapposte superiori) e di sinistra (tracce sovrapposte inferiori)  
File:Bruxer SP2.jpg|'''Figure 7:''' <math>\gamma _3=</math> Periodo silente meccanico rilevato elettrofisiologicamente sui masseteri di destra (tracce sovrapposte superiori) e di sinistra (tracce sovrapposte inferiori)  
</gallery></center>  
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