Temporal Summation of Heat Pain in Temporomandibular Disorder Patients

Aims: To compare patients with temporomandibular disorders (TMD) to control subjects on two measures of central processing, ie, temporal summation of heat pain and decay of subsequent aftersensations, following thermal stimulation in both a trigeminal and extratrigeminal area. Methods: A “wind-up” protocol was used in which 19 female TMD patients and 17 female controls were exposed to 15 heat stimuli at a rate of 0.3 Hz. Numeric pain ratings were elicited after the 1st, 5th, 10th, and 15th stimulus presentation and every 15 seconds after final presentation (aftersensations) for up to 2 minutes. In separate trials, the thermode was placed on the thenar eminence of the hand and the skin overlying the masseter muscle. Results: Groups did not differ with respect to the slope of wind-up when stimulated at either anatomic site, although asymptotic levels occurred sooner for TMD patients than for controls. In analysis of aftersensations, a significant group X site X time interaction was detected, in which TMD patients experienced more prolonged painful aftersensations than controls when stimulated on the skin overlying the masseter muscles. Conclusion: These results are consistent with the presence of enhanced central sensitivity in TMD and suggest that this sensitivity may be largely confined to the region of clinical pain. This contrasts with conditions such as fibromyalgia, where central sensitivity appears to be widespread.

aftersensations; chronic pain; temporal summation; temporomandibular disorders; wind-up

1. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, criteria, examina- tions and specifications, critique. J Craniomandib Disord 1992;6:301–355.

2. LeResche L, Dworkin SF, Sommers EE, Truelove EL. An epidemiologic evaluation of two diagnostic classification schemes for temporomandibular disorders. J Prosthet Dent 1991;65:131–137.

3. Stohler CS. Phenomenology, epidemiology, and natural progression of the muscular temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:77–81.

4. Maixner W, Fillingim R, Sigurdsson A, Kincaid S, Silva S. Sensitivity of patients with painful temporomandibular disorders to experimentally evoked pain: Evidence for altered temporal summation of pain. Pain 1998;76:71–81.

5. Svensson P, List T, Hector G. Analysis of stimulus-evoked pain in patients with myofascial temporomandibular pain disorders. Pain 2001;92:399–409.

6. Svensson P, Arendt-Nielsen L, Nielsen H, Larsen JK. Effect of chronic and experimental jaw muscle pain on pain-pressure thresholds and stimulus-response curves. J Orofac Pain 1995;9:347–356.

7. Maixner W, Fillingim R, Booker D, Sigurdsson A. Sensitivity of patients with painful temporomandibular disorders to experimentally evoked pain. Pain 1995;63: 341–351.

8. Maixner W, Fillingim R, Kincaid S, Sigurdsson A, Harris MB. Relationship between pain sensitivity and resting arterial blood pressure in patients with painful temporomandibular disorders. Psychosom Med 1997;59:503–511.

9. Bragdon EE, Light KC, Costello NL, et al. Group differences in pain modulation: Pain-free women compared to pain-free men and to women with TMD. Pain 2002;96: 227–237.

10. Malow RM, Grimm L, Olson RE. Differences in pain perception between myofascial pain dysfunction patients and normal subjects: A signal detection analysis. J Psychosom Res 1980;24:303–309.

11. Kashima K, Rahman OI, Sakoda S, Shiba R. Increased pain sensitivity of the upper extremities of TMD patients with myalgia to experimentally-evoked noxious stimulation: Possibility of worsened endogenous opioid systems. Cranio 1999;17:241–246.

12. Carlson CR, Reid KI, Curran SL, et al. Psychological and physiological parameters of masticatory muscle pain. Pain 1998;76:297–307.

13. Costello NL, Bragdon EE, Light KC, et al. Temporomandibular disorder and optimism: Relationships to ischemic pain sensitivity and interleukin-6. Pain 2002; 100:99–110.

14. Davidson RM, Gale EN. Cutaneous sensory thresholds from skin overlying masseter and forearm in MPD patients and controls. J Dent Res 1983;62:555–558.

15. Price DD, Harkins SW. Combined use of experimental pain and visual analogue scales in providing standardized measurement of clinical pain. Clin J Pain 1987;3:1–8.

16. Curran SL, Carlson CR, Okeson JP. Emotional and physiologic responses to laboratory challenges: Patients with temporomandibular disorders versus matched control subjects. J Orofac Pain 1996;10:141–150.

17. Sarlani E, Greenspan JD. Evidence for generalized hyperalgesia in temporomandibular disorders patients. Pain 2003;102:221–226.

18. Price DD. Characteristics of second pain and flexion reflexes indicative of prolonged central summation. Exp Neurol 1972;37:371–387.

19. Herrero JF, Laird JM, Lopez-Garcia JA. Wind-up of spinal cord neurones and pain sensation: Much ado about something? Progr Neurobiol 2000;61:169–203.

20. Price DD, Hu JW, Dubner R, Gracely RH. Peripheral suppression of first pain and central summation of second pain evoked by noxious heat pulses. Pain 1977;3:57–68.

21. Vierck CJ Jr, Cannon RL, Fry G, Maixner W, Whitsel BL. Characteristics of temporal summation of second pain sensations elicited by brief contact of glabrous skin by a preheated thermode. J Neurophysiol 1997;78:992–1002.

22. Woolf CJ. Wind-up and central sensitization are not equivalent. Pain 1996;66:105–108.

23. Price DD, Staud R. Neurobiology of fibromyalgia syndrome. J Rheumatol 2005;75(suppl):22–28.

24. Wright EF, Des Rosier KF, Clark MK, Bifano SL. Identifying undiagnosed rheumatic disorders among patients with TMD. J Am Dent Assoc 1997;128:738–744.

25. Marbach JJ. Is myofascial face pain a regional expression of fibromyalgia? J Musculoskel Pain 1995;3:93–97.

26. Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000;160:221–227.

27. Korszun A, Papadopoulos E, Demitrack M, Engleberg C, Crofford L. The relationship between temporomandibular disorders and stress-associated syndromes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:416–420.

28. Plesh O, Wolfe F, Lane N. The relationship between fibromyalgia and temporomandibular disorders: Prevalence and symptom severity. J Rheumatol 1996;23: 1948–1952.

29. Dao TT, Reynolds WJ, Tenenbaum HC. Comorbidity between myofascial pain of the masticatory muscles and fibromyalgia. J Orofac Pain 1997;11:232–241.

30. Raphael KG, Marbach JJ, Klausner J. Myofascial face pain. Clinical characteristics of those with regional vs. widespread pain. J Am Dent Assoc 2000;131:161–171.

31. Sarlani E, Grace EG, Reynolds MA, Greenspan JD. Evidence for up-regulated central nociceptive processing in patients with masticatory myofascial pain. J Orofac Pain 2004;18:41–55.

32. Sarlani E, Greenspan JD. Why look in the brain for answers to temporomandibular disorder pain? Cells Tissues Organs 2005;180:69–75.

33. Maixner W. Is pain sensitivity a predictive factor for the development of painful temporomandibular disorders? Presented at American Pain Society Annual Meeting. Chicago, IL, 2003.

34. Bhalang K, Slade GD, Sigurdsson A, Maixner W. Pain sensitivity and the development of TMD—Initial outcomes from a three-year prospective study [abstract 1874]. In: Proceedings of the International Association for Dental Research 81st, General Session, Göteborg, Sweden, 2002.

35. Bhalang K, Sigurdsson A, Slade GD, Maixner W. Central sensitization and the development of temporomandibular disorders [abstract]. J Pain 2003;4(suppl 1):12.

36. Marbach JJ, Schwartz S, Link BG. The control group conundrum in chronic pain case/control studies. Clin J Pain 1992;8:39–43.

37. Spielberger C, Gorsuch R, Lushene R. Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press, 1970.

38. Mauderli AP, Vierck CJ Jr, Cannon RL, Rodrigues A, Shen C. Relationships between skin temperature and temporal summation of heat and cold pain. J Neurophysiol 2003;90:100–109.

39. Price DD, Staud R, Robinson ME, Mauderli AP, Cannon R, Vierck CJ. Enhanced temporal summation of second pain and its central modulation in fibromyalgia patients. Pain 2002;99:49–59.

40. Staud R, Vierck CJ, Cannon RL, Mauderli AP, Price DD. Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Pain 2001;91:165–175.

41. Staud R, Price DD, Robinson ME, Mauderli AP, Vierck CJ. Maintenance of wind-up of second pain requires less frequent stimulation in fibromyalgia patients compared to normal controls. Pain 2004;110:689–696.

42. Singer JD, Willett JB. Applied longitudinal data analysis: Modeling change an event occurrence. New York: Oxford University Press, 2003.

43. Schwartz S, Link BG. The ‘well control’ artefact in case/control studies of specific psychiatric disorders. Psychol Med 1989;19:737–742.

44. Staud R, Price DD, Fillingim RB. Advanced continuous-contact heat pulse design for efficient temporal summation of second pain (wind-up). J Pain 2006;7:575–582.

45. Staud R, Robinson ME, Vierck CJ Jr, Cannon RC, Mauderli AP, Price DD. Ratings of experimental pain and pain-related negative affect predict clinical pain in patients with fibromyalgia syndrome. Pain 2003;105:215–222.

46. Staud R, Cannon RC, Mauderli AP, Robinson ME, Price DD, Vierck CJ Jr. Temporal summation of pain from mechanical stimulation of muscle tissue in normal controls and subjects with fibromyalgia syndrome. Pain 2003;102: 87–95.