Temporomandibular disorders (TMD) embrace pain and dysfunction in the temporomandibular joint (TMJ) and jaw muscles. TMD is a prevalent condition in the population and constitutes a significant health problem. Knowledge of factors influencing the onset and course of TMD is important in preventive care and development of treatment strategies as well as in clinical decision making. The aim of this thesis was to gain knowledge of whether variations in dental occlusion, bruxism, spinal pain and gender predicted the development and course of TMD. The study population comprised 371 undergraduate dental students. A questionnaire was used to obtain case histories. Clinical examination included the function of the TMJ, jaw muscles, maximal jaw mobility, the morphological occlusion, and contact patterns in centric and eccentric positions. The examinations were performed at start, and after 12 and 24 months. In total, 280 subjects were examined at all three occasions. The incidence of TMJ pain and dysfunction was high among both males and females. The course composed onset, recovery and maintenance resulting in a fluctuating pattern. Females were more likely to have persistent TMJ pain and dysfunction than males. The incidence and persistence of jaw muscle signs and symptoms was high and significantly more common in females. A similar fluctuating pattern as for TMJ pain and dysfunction was found. Crossbite predicted onset and persistence of TMJ pain and dysfunction; mandibular instability in centric positions predicted persistent TMJ pain and dysfunction, as well as persistent jaw muscle signs or symptoms. Reported bruxism increased the risk for TMJ pain and dysfunction but did not significantly affect the course of jaw muscle signs and symptoms. Spinal pain at baseline predicted the onset of jaw pain, headaches, and TMD pain. Signs of TMD at baseline predicted the onset of non-pain symptoms of TMD, jaw pain, headaches, and spinal pain. In conclusion, the results in this thesis show high incidence rates for TMD, headaches, and spinal pain among dental students. Crossbite, mandibular instability, reported bruxism, as well as female gender were identified as contributing risk factors. Spinal pain and TMD mutually predicted each other, indicating common pathophysiological mechanisms and individual vulnerability. The findings support a multidisciplinary approach, and it is recommended that the status and function of the jaw system be considered in patients with spinal pain.

Einleitung: Im Rahmen eines Projekts wird untersucht, ob sich medizinische Laien mit einem neugestalteten internetbasierten Informationssystem besser informieren können, als dieses mit Suchmaschinen und Gesundheitsportalen möglich ist. Die Evaluation eines Systems zur Informationsversorgung von Kopfschmerzpatienten ist nur dann sinnvoll, wenn tatsächlich viele Menschen im deutschsprachigen Raum unter Kopfschmerzen leiden und mit Ihren Beschwerden eher das Internet als einen Arzt konsultieren. Daher wurde in drei Studien die Prävalenz von Kopfschmerzen und die damit verbundene Arztkonsultationsquote untersucht. Methode: Dazu wurden 2000 Versicherte der BARMER Ersatzkasse, ca. 9000 Studenten der Hochschule Bremen und ca. 1000 Studenten der Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik in Tirol, Österreich (UMIT) angeschrieben und gefragt, ob sie unter Kopfschmerzen leiden und wenn ja, ob sie für ihre Kopfschmerzen bereits eine ärztliche Diagnose haben. Insgesamt nahmen 521 Personen an der Untersuchung teil. Ergebnisse: Davon litten 292 Teilnehmer (56 %) unter Kopfschmerzen. Eine ärztliche Diagnose für diese hatten 52 (18 %). Alles in allem zeigt sich damit eine etwas geringere Kopfschmerzprävalenz als in den vorangegangen Studien. Die in der Literatur genannte Arztkonsultationsquote wird bestätigt. Diskussion: Die Auswertung der drei Studien zeigte, dass die Prävalenz von Kopfschmerzen weiterhin hoch und die damit verbundene Arztkonsultationsquote immer noch gering ist. / Introduction: In a project, it is investigated whether a newly designed web-information system can better inform medical laymen than traditional search engines and health portals. The evaluation of a system for providing information to headache patients is only useful when in fact many people suffer from headaches in the German speaking area and if these people with their complaints rather consult the Internet than a practitioner. Therefore, in three studies the prevalence of headache and the associated physician consultation rate was examined. Method: About 9000 students of the University of Applied Sciences Bremen, 2000 insurants of the BARMER, and about 1000 students of the University of Health Sciences, Medical Informatics and technology Tyrol, Austria (UMIT) were asked if they suffer from headaches and if so whether they already have a medical diagnosis. A total of 521 persons participated in the investigation. Results: From headaches suffered 292 (56%) participants. A medical diagnosis for these had 52 (18%). All in all, it shows slightly lower headache prevalence than found in previous studies. The medical consultation rate cited in the literature is confirmed. Discussion: The evaluation of the three studies showed that the prevalence of headache remains high and the associated physician consultation rate is still low.

abstract: ABSTRACT Approximately 3.5% of adolescents in the United States have chronic daily headache (CDH). Chronic daily headaches in adolescents are often refractory to the adult pharmacological interventions. And as a result, adolescents typically experience increased levels of stress, which exacerbates their headaches. Chronic daily headaches negatively impact both the adolescent and their family. Adolescents with CDHs frequently exemplify comorbid psychiatric symptoms such as anxiety, depression, and increased risk for suicide. Risk factors for CDH in adolescents have been well studied; however, few studies have focused on psychologically based interventions to enhance effective coping, positive mental health, and pain relief in this group of teens. Given the paucity of psychologically focused interventions in this group, further research is necessary to test and develop the effectiveness of cognitive behavioral skills building (CBSB) interventions. This pilot study focused on the use of a CBSB intervention that emphasized problem solving, cue recognition, effective communication, behavior modeling, cognitive reappraisal, stress management, effective coping, and positive thinking. A randomized controlled trial pilot study was conducted. The intervention group received a seven-week intervention focused on CBSB techniques and headache education, while the comparison headache education group received a seven-week program focused on basic headache hygiene measures (e.g., adequate sleep, adequate hydration, dietary triggers, environmental triggers). The total sample included 32 adolescents inclusive of the ages 13 and 17 years. Paired t-tests resulted in significant preliminary positive effects for COPE-HEP on anxiety, depression, beliefs, headache disability, headache frequency, and headache duration. Comparison group education resulted in significant preliminary positive effects on anxiety, depression, headache disability, headache frequency, headache pain level, headache duration, and medication frequency. There were no significant changes over time in means of parent perception of pain interference for both groups. Independent t-tests revealed that COPE-HEP teens had significantly less anxiety and headache duration at post-intervention. The acceptability of the COPE-HEP intervention with adolescents with CDHs in a specialty care setting is supported by this study, while the feasibility of conducting this study in a specialty care setting is partially supported. These findings support a need to refine the intervention and test both its short and long-term effects in a full-scale randomized controlled trial with adolescents who have CDHs. / Dissertation/Thesis / Ph.D. Nursing and Healthcare Innovation 2012

INTRODUÇÃO. A comorbidade entre cefaléias e transtornos psiquiátricos vem sendo enfatizada como um dos aspectos mais importantes no manejo dos pacientes com cefaléias primárias. Os transtornos de ansiedade, além dos de humor, são um dos diagnósticos de maior importância neste contexto. O transtorno de ansiedade generalizada (TAG) é o transtorno de ansiedade mais associado à enxaqueca. Apesar da relevância do tema, é surpreendente a escassez de estudos sobre o impacto das cefaléias primárias em pacientes com TAG. OBJETIVO. O objetivo deste estudo foi de avaliar a prevalência ao longo da vida e o impacto das cefaléias primárias em pacientes com e sem TAG. MÉTODOS. Sessenta pacientes foram incluídos no estudo: 30 pacientes com diagnóstico de TAG, de acordo com a entrevista estruturada SCID-1/P, e 30 controles saudáveis. Todos os pacientes passaram por entrevista clínica enfocando variáveis demográficas (idade, sexo, escolaridade e estado civil), antropométricas (peso, altura e IMC), relativas às cefaléias (intensidade, duração, freqüência, aura, tempo de história e consumo de analgésicos), gravidade da sintomatologia (ansiosa, depressiva, de fadiga e de sonolência diurna) e conseqüências médico-sociais (incapacidade funcional, utilização de serviços de saúde e qualidade de vida). As cefaléias primárias foram avaliadas através de entrevista estruturada e foram empregados os critérios da Classificação Internacional das Cefaléias (2a edição) para realização de seu diagnóstico. RESULTADOS. 86,6% dos pacientes com TAG receberam algum diagnóstico de cefaléia, sendo a enxaqueca o diagnóstico mais comum. Comparados aos controles, os pacientes com TAG apresentaram odds ratio maior para cefaléias primárias (RC=7,43) e também para enxaqueca (RC=13,00), enxaqueca episódica (RC=6,88) e aura (RC=10,55). Já nos controles, apenas 47% receberam algum diagnóstico de cefaléia, sendo CTT episódica infreqüente o diagnóstico mais comum. DISCUSSÃO/CONCLUSÃO. O diagnóstico de cefaléias primárias é mais comum em pacientes com TAG do que nos controles. A enxaqueca é o diagnóstico mais comum em pacientes com TAG e também mais freqüente em TAG que em controles. A cefaléia do tipo tensional (CTT) freqüente é igualmente comum em ambos os grupos. É importante realizar o diagnóstico de cefaléias primárias em pacientes com transtornos de ansiedade, em especial o TAG, pois a sua correta avaliação deve implicar em um manejo mais preciso dos pacientes com TAG e resultar em desfechos clínicos mais favoráveis. / OBJECTIVES. Anxiety disorders and headaches are comorbid conditions, but no research has been done on the prevalence and impact of primary headaches in generalized anxiety disorder (GAD) patients. The study\'s aim was to analyze lifetime prevalence and impact of primary headaches in patients with and without generalized anxiety disorder. METHODS. Sixty participants were enrolled in the study; 30 GAD patients diagnosed according to the DSM-IV were compared to 30 healthy control subjects. All patients were interviewed for psychiatric assessment using the SCID-I/P. Primary headaches were diagnosed using ICHD-II criteria for structured interview. RESULTS. Migraine was the most common diagnosis in generalized anxiety disorder patients. The prevalence of migraine was highest among GAD patients as opposed to controls (66.7% vs 13.3%; p<0.001; OR=13.00; 95% CI=3.55-47.6), episodic migraine (43.3% vs 10%; p=0.004; OR=6.88; 95% CI=1.71-27.75), chronic daily headache (20% vs 0; p=0.024) and aura (26.6% vs 3.3%; p=0.026; OR=10.55; 95% CI=1.23-90.67). Tension Type Headache (TTH) was equal for controls and the GAD group (20% vs 33.3%; p=0.243).The characteristics of migraines (frequency, intensity, duration, and consumption of analgesics), symptoms such as anxiety, depression, fatigue, and daytime sleepiness, as well as the medical-social consequences (functional incapacity, use of health services and quality of life) were worse in GAD patients than in controls. CONCLUSION. Primary headaches in general, and migraine in particular, are significantly more common in GAD patients than controls. GAD aggravates headaches. Primary headache diagnosis is important for anxiety disorder patients, particularly those with GAD, since correct assessment may lead to better patient management and clinical outcomes.

Einleitung: Im Rahmen eines Projekts wird untersucht, ob sich medizinische Laien mit einem neugestalteten internetbasierten Informationssystem besser informieren können, als dieses mit Suchmaschinen und Gesundheitsportalen möglich ist. Die Evaluation eines Systems zur Informationsversorgung von Kopfschmerzpatienten ist nur dann sinnvoll, wenn tatsächlich viele Menschen im deutschsprachigen Raum unter Kopfschmerzen leiden und mit Ihren Beschwerden eher das Internet als einen Arzt konsultieren. Daher wurde in drei Studien die Prävalenz von Kopfschmerzen und die damit verbundene Arztkonsultationsquote untersucht. Methode: Dazu wurden 2000 Versicherte der BARMER Ersatzkasse, ca. 9000 Studenten der Hochschule Bremen und ca. 1000 Studenten der Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik in Tirol, Österreich (UMIT) angeschrieben und gefragt, ob sie unter Kopfschmerzen leiden und wenn ja, ob sie für ihre Kopfschmerzen bereits eine ärztliche Diagnose haben. Insgesamt nahmen 521 Personen an der Untersuchung teil. Ergebnisse: Davon litten 292 Teilnehmer (56 %) unter Kopfschmerzen. Eine ärztliche Diagnose für diese hatten 52 (18 %). Alles in allem zeigt sich damit eine etwas geringere Kopfschmerzprävalenz als in den vorangegangen Studien. Die in der Literatur genannte Arztkonsultationsquote wird bestätigt. Diskussion: Die Auswertung der drei Studien zeigte, dass die Prävalenz von Kopfschmerzen weiterhin hoch und die damit verbundene Arztkonsultationsquote immer noch gering ist. / Introduction: In a project, it is investigated whether a newly designed web-information system can better inform medical laymen than traditional search engines and health portals. The evaluation of a system for providing information to headache patients is only useful when in fact many people suffer from headaches in the German speaking area and if these people with their complaints rather consult the Internet than a practitioner. Therefore, in three studies the prevalence of headache and the associated physician consultation rate was examined. Method: About 9000 students of the University of Applied Sciences Bremen, 2000 insurants of the BARMER, and about 1000 students of the University of Health Sciences, Medical Informatics and technology Tyrol, Austria (UMIT) were asked if they suffer from headaches and if so whether they already have a medical diagnosis. A total of 521 persons participated in the investigation. Results: From headaches suffered 292 (56%) participants. A medical diagnosis for these had 52 (18%). All in all, it shows slightly lower headache prevalence than found in previous studies. The medical consultation rate cited in the literature is confirmed. Discussion: The evaluation of the three studies showed that the prevalence of headache remains high and the associated physician consultation rate is still low.

Both spinal pain and temporomandibular disorders (TMD) commonly occur in the general population. Previous studies demonstrate neurophysiologic and biomechanical couplings between the trigeminal and cervical regions. This investigation tested the null hypothesis of no relationship between spinal pain (neck, shoulder and/or low back) and TMD, by using questionnaires and clinical examinations of the jaw function. In an age- and sex-matched case-control study, the specific aim was to compare the prevalence of signs and symptoms of TMD among cases with long-term spinal pain and controls without spinal pain. The results showed that subjects with spinal pain had signs and symptoms of TMD significantly more often than did controls. The associations remained after excluding all participants with jaw pain. Furthermore, the comorbidity pattern was similar, regardless of location of spinal pain. In a cross-sectional study, the specific aim was to test whether there is a reciprocal cross-sectional dose-response-like relationship between spinal pain and TMD. Two different designs were used, one with frequency/severity of spinal pain as independent variable, and the other, with frequency/severity of TMD symptoms as independent variable. The analysis showed increasing odds for presence of TMD symptoms with increasing frequency/severity of spinal pain, and increasing odds for presence of spinal pain with increasing frequency/severity of TMD symptoms. In a case-control study within a 2-year prospective cohort, the specific aim was to test whether there is a reciprocal temporal relationship between signs and symptoms in trigeminally, and symptoms in spinally, innervated areas. Incidence of symptoms in these areas was analyzed in relation to presence of spinal pain, headaches, and signs and symptoms of TMD at baseline. The main findings were that presence of signs of TMD at baseline increased the onset of spinal pain and symptoms in the trigeminal area, and that spinal pain increased the onset of symptoms in the trigeminal area. An augmentation effect between the significant baseline variables was observed for the incidence of headaches and jaw pain. In conclusion, the investigation demonstrated a cross-sectional and temporal relationship between spinal pain and TMD; thus, the null hypothesis was rejected. The results indicate common pathophysiological mechanisms in the development of spinal pain and TMD. The comorbidity and reciprocal influence that were found call for an integrated and multidimensional approach in the management of individuals with long-term spinal pain and TMD.

Review of previous research on cultural differences in pain experience and/or pain behavior revealed that cultural affiliation affects pain perception and response. Unfortunately, the many inconsistent findings in the literature on cultural differences in pain experience and behavior have made interpretations and comparisons of results problematic. These inconsistent findings could be attributed to variations in acculturation level among cultural groups. The purpose of this study was to investigate cultural differences in pain experience (assessed by McGill Pain Questionnaire, the Box Scale, the Headache Pain Drawing, and the Headache Questionnaire) and pain behavior (measured by determining medication use and interference of daily functioning due to headaches) among Mexican (n = 43), Mexican American (n = 36), and Anglo American (n = 50) female chronic headache pain sufferers. The contribution of acculturation to differences in pain experience and behavior among cultural groups was measured by the Acculturation Rating Scale for Mexican Americans. The three cultural groups of women significantly differed on pain experience and pain behavior. Specifically, Mexican women experienced their headache pain more intensely, severely, and emotionally than Mexican American and Anglo American women. Furthermore, Mexican women were more willing to verbally express their pain than the other two groups. As for pain behavior, Mexican women took more medication and reported more severe inhibition of daily activities due to headaches than Mexican American and Anglo American women. Ethnic identity, ethnic pride, and language preference were factors in the acculturation process which contributed the most to women's chronic pain experience and behavior. The greatest variability occurred within the Mexican American group of women who perceived themselves as being more Mexican in attitudes and/or behaviors, but more similar to Anglo American in their pain experience and pain behavior. Results are explained using biocultural multidimensional pain theory, social learning theory, and acculturation theory.

Dissertation submitted in partial compliance with the requirements for a Master's Degree in Technology: Chiropractic, Durban University of Technology, 2010. / Forward head posture (FHP) is a common postural abnormality, often associated with myofascial trigger points which can result in head and neck pain. The craniovertebral (CV) angle lies between a horizontal line running through C7 spinous process and a line connecting C7 spinous process to the tragus of the ear. The smaller the angle the greater the FHP. Cervical musculoskeletal abnormalities have often been linked to headache types, most especially episodic tension-type headache (ETTH) and cervicogenic headaches (CGH). Objectives: To determine whether an association exists between FHP, distance of the external auditory meatus (EAM) from the plumbline and cervical range of motion and the presentation of ETTH and CGH. Method: This was a quantitative comparative study (n=60) comparing three equal groups, one with ETTH, CGH and healthy controls. The FHP of the Subjects FHP was assessed by measuring the CV angle. A lateral digital photograph was taken to assess the distance of the external auditory meatus from the plumbline. Lastly, cervical range of motion was measured. The two symptomatic groups also received a headache diary for a fourteen day period monitoring frequency, intensity and duration of their headaches. Result: The two symptomatic groups had a smaller CV angle and a greater distance from the plumbline (p<0.05) than the asymptomatic group. The asymptomatic group had a significantly greater flexion (p=0.009), extension (p=0.038) and left rotation (p=0.018) range of motion than the two symptomatic groups. The CGH group had a significant positive correlation between the distance of the EAM from the plumbline and the intensity of headaches. The ETTH group had a significant positive correlation between the right craniovertebral angle and the mean duration of headaches. Conclusion: Therefore, it can be concluded that patients presenting with ETTH and/or CGH may have associated postural abnormalities that may act as a trigger or a contributory factor to the presenting headache. / Durban University of Technology

Dissertation submitted in partial compliance with the requirements for a Master's Degree in Technology: Chiropractic, Durban University of Technology, 2010. / Forward head posture (FHP) is a common postural abnormality, often associated with myofascial trigger points which can result in head and neck pain. The craniovertebral (CV) angle lies between a horizontal line running through C7 spinous process and a line connecting C7 spinous process to the tragus of the ear. The smaller the angle the greater the FHP. Cervical musculoskeletal abnormalities have often been linked to headache types, most especially episodic tension-type headache (ETTH) and cervicogenic headaches (CGH). Objectives: To determine whether an association exists between FHP, distance of the external auditory meatus (EAM) from the plumbline and cervical range of motion and the presentation of ETTH and CGH. Method: This was a quantitative comparative study (n=60) comparing three equal groups, one with ETTH, CGH and healthy controls. The FHP of the Subjects FHP was assessed by measuring the CV angle. A lateral digital photograph was taken to assess the distance of the external auditory meatus from the plumbline. Lastly, cervical range of motion was measured. The two symptomatic groups also received a headache diary for a fourteen day period monitoring frequency, intensity and duration of their headaches. Result: The two symptomatic groups had a smaller CV angle and a greater distance from the plumbline (p<0.05) than the asymptomatic group. The asymptomatic group had a significantly greater flexion (p=0.009), extension (p=0.038) and left rotation (p=0.018) range of motion than the two symptomatic groups. The CGH group had a significant positive correlation between the distance of the EAM from the plumbline and the intensity of headaches. The ETTH group had a significant positive correlation between the right craniovertebral angle and the mean duration of headaches. Conclusion: Therefore, it can be concluded that patients presenting with ETTH and/or CGH may have associated postural abnormalities that may act as a trigger or a contributory factor to the presenting headache. / Durban University of Technology / M

Eine stetig wachsende Zahl von Nutzern sucht im Internet nach Gesundheitsinformationen. Hierzu steht ihnen eine Vielzahl ganz unterschiedlicher Anbieter zur Verfügung, die bei divergierenden Interessen gesundheitsrelevante Angebote im Internet vorhalten. Abgesehen von der Informationsflut, mit der die Nutzer bei der Suche überhäuft werden, erhalten sie auch falsche, irreführende, veraltete und sogar gesundheitsgefährdende Informationen. In den letzten zehn Jahren haben verschiedene Wissenschaftler die Anforderungen an ein ideales Gesundheitsinformationssystem ermittelt. Im Rahmen des in diesem Beitrag beschriebenen Projekts wurde ein Gesundheitsinformationssystem als Prototyp zur anamnesebezogenen, internetbasierten Patienteninformation entwickelt und anhand einer Studie evaluiert. Dabei wird die Untersuchung auf deutschsprachige Erwachsene mit Kopfschmerzen eingegrenzt. Insgesamt wird die Hypothese überprüft, dass eine angeleitete, anamnesebezogene Internetsuche für den Patienten bessere Ergebnisse liefert, als dies durch die herkömmliche Nutzung von Gesundheitsportalen oder Suchmaschinen erreicht werden kann. Zur Evaluation wurde eine kontrollierte Zweigruppenstudie mit insgesamt 140 Teilnehmern in zwei Studienabschnitten durchgeführt. Dabei wurde im ersten Abschnitt festgestellt, dass bei einfach strukturierten Krankheitsfällen das Informationssystem gleichgute Ergebnisse liefert wie die herkömmliche Suche. Im zweiten Abschnitt konnte allerdings festgestellt werden, dass bei komplexen Kopfschmerzfällen mit Hilfe des Prototyps signifikant (P=0,031) bessere Diagnosen gestellt werden konnten als ohne. Medizinische Expertensysteme in Kombination mit einer Meta-Suche nach maßgeschneiderten qualitätsgesicherten Informationen erweisen sich als probate Möglichkeit, den Ansprüchen an eine geeignete Versorgung mit Gesundheitsinformationen gerecht zu werden. / A steadily increasing number of users search for health information online. Therefore, a multitude of totally different providers with diverging interests offer information. Apart from the information overload the users are flooded with, they may access false, misleading or even life threatening information. In the last 10 years scientists have determined the requirements of an ideal health information system. In the study described in this paper a prototype health information system providing anamnesis related internet-based consumer health information is evaluated. In total, the hypothesis that a computer-aided anamnesis-related internet search provides better results than the use of conventional search engines or health portals is evaluated. For evaluation a randomised controlled study with 140 participants has been conducted in two study sections. In the first section it was found, that for a less complex diagnosis the prototype information system did equally well as the conventional information retrieval. In the second study section it was found, that dealing with complex headache cases participants using the prototype determined significantly better (P=0.031) diagnoses than the control group did without prototype support. It has been shown, that medical expert systems in combination with a meta-search for tailored quality controlled information represents a feasible strategy to provide reliable health information.