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To correctly understand this heading:
Remember that any stressed person who continuously clenches his teeth can elicite remote pain and associated dyscomforts from teeth (which are not only painful organs but also tactile one like the thumb and the index in opposite situation)
If You are interested the scientifical data are shown lower.
idee.jpg Don't forget to consult the associated headlings : "Clinical Data" and "Witness and experience"

(specially at waking up)

Comment :

we said that a too intense and/or prolonged dental stimulation might initiate far from mouth pain with or without associated dyscomforts (tinnitus, nausea, dizziness, itching in the ear) in a stressed person. So the visitor can :
- strongly clench the teeth
- or without effort keep the teeth contacted (...)
These bad habits could both generate invalidating pain and dyscomforts which are deconcerting for the clinician..

scientific data

Hartmann F (1992) Cranio-mandibular disorders inducing nausea and vomiting. In : Mechanisms and Control of Emesis (Bianchi AL, Grélot AD, Miller GI, King GI) (ed) Colloque INSERM/John Libbey Eurotext Ltd C: 51-8.

Temporo Mandibular Disorders (TMD) often reflect a dysfunction of the Temporomandibular Joint (TMJ). They can occur after whiplash, difficult back teeth extraction and orthodontic procedures. The symptoms sometimes inclued nausea and /or vomiting. Clinical experiments combined with neuroanatomical labelling data have lead to the development accounting for the role of bruxism (clenching) in the genesis and continuation of these emetic symptoms in CMD.

Cranio Mandibular Disorders have recently been classified and subdivided by the American Academy Association of Cranio Mandibular Disorders, (Mac Neill, 1990) into two main categories, namely internal derangements (articular or arthrogenic disorders) and external derangements (muscular or myogenic disorders) of the Temporo Mandibular Joint (TMJ), (Hanson, 1988). Farrar & Mac Carthy (1982), have established that a dislocation of the TMJ meniscus can occur which is sometimes but not always susceptible to reduction. Patient include limitation of mouth opening, deviation of the mandible and clicking at the level of the TMJ.

Patients suffering from internal derangement of the TMJ complain of headache, otalgia, pain in the pre-auricular area, behind the eye, and in the neck, shoulder or arm ; other symptoms can include vertigo, tachycardia, bruxism, and digestive problems (Farrar & Mac Carthy, 1982). We have attempted to etablish by questioning our patients what kind of digestive problems referred to by these authors actually ina and vomiting. To our knowledge, the only relevant information available about problems of this kind is that in the study by (Lashley & Elder, 1982). These authors reported five case studies on patients with hyperemesis, migraine, bruxism and mixed headache who underwent clinical biofeedback treatment. The female patient with bruxism was referred for deep muscle relaxation training and EMG feedback. Her major complaint however was bruxism which had occurred mostly at night over the previous 15 years.

The present study deals with 161 patients admitted to our Oro Facial Pain Center with TMJ dislocation, The diagnosis was etablished using the following procedures.

Questionning the patients 

The patients reported that they suffered from pain in various regions (headache, otalgia, neck and shoulder pain), as well as from emesis, i.e., nausea and / or vomiting.
It was sometimes established only with some difficulty that some of the patient also have bruxism. In this cases the bruxism was mostly not of the teeth grinding but of the teeth clenching type. When no grinding occurs, there is no wearing of the dental enamel. Cases of bruxism involving only clenching therefore tend to be overlooked by physicians.

Tests applied : 

Endo-buccal palpation

Palpation of the lateral pterygoid muscle, (Travell & Simons, 1983, Bell,1985, Hartmann & Cucchi 1987, 1988, Hartmann & Sarat ,1988). This palpation nearly always induced hyperalgic effects. Here the palpation consisted of placing the small finger behind the superior maxillary tuberosity, working towards the ears. This palpation triggers the “jump sign” or “twitch response”, (Travell & Simons, 1983). This nociceptive response indicates the state of contraction of the palpated muscle, although the diagnostic value of direct muscle palpation has sometimes been questioned, (Ash,1986), White, 1985). When a physician palpates the Mac Burney point, he is actually palpating the region to wich the nerves of the appendix project and probably not the appendix itself. Likewise, endobuccal applied to the pterygoid region, as descibed above, triggers "jump sign" nociceptive messages wich reflect lateral pterygoid dysfunction. These dysfunctions has been found to accompany established cases of Cranio Mandibular Disorders (CMD).

Exo-buccal palpation
We systematically looked for three painful points which are often present in patients with CMD, (Hartmann & Cucchi, 1987 1988, Hartmann et al., 1988), whether accompanied or otherwise by nausea and / or vomiting. We checked for pain in response to pressure applied to the sterno-cleido-mastoid muscle, the ipsilateral temporal muscle, and at the supra-internal angle of the orbital arcade. For these painful responses to consistute a valid diagnostic sign, it is indispensable that all three should be present at once. All these patients had been treated previously with drugs to combat nausea and vomiting with no succes

Complementary tests : 

Tomography, arthrography 

We systematically prescribed tomography for these patients. This often made it possible to detect malposition of the condyle in the glenoid cavity, which could be of variable extent and was sometimes reminiscent of a meniscal dislocation and therefore called for arthrography, (Helms & Katzberg, 1983). 
Out of the 161 arthrographies performed :

- a reducible meniscal dislocation was observed in 120 cases

- and a meniscal dislocation which was not reducible in 41 cases

Fonctionnal exploration of the trigeminal nerve
The trigeminal nerve was explored as previouly described by Papy & Hartmann (1989) involving :

- EMG of the temporal muscle

- Blink reflex test, involving interactions between the facial and trigeminal nerves

- Evoked somesthetic potential recordings on the trigeminal nerve;


The treatment

First we always attempted to help the patient by counselling, where the following advice was given :

1 - to make a conscious effort not to clench their teeth

2 - to clench their lips rather than their teeth, in agreement with data by Bratzlavsky (1972). This author has demonstrated that activation of the 7th facial nerve inhibits elevator muscle motoneurones
3 - to put up red stickers around the house, car, and office reminding the patient that “clenching the teeth causes headache, pain, nausea and vomiting. 
This procedure was most effective, and in two cases the counselling alone resulted in the disappearance of the vomiting. In the other patients, the counselling alone did not suffice and we therefore proceeded as follows :

Local myoresolution
Injection of anesthetic without any vasoconstrictor such as mepivacaine or lidocaine (= xylocaine) into the both infra temporal fossa using a method we have described previously (Hartmann et al., 1988). In addition to their anesthetic effects, mepivacaine or lidocaine exert a myoresolutive action (Bell, 1985 ; Gelb , 1977 ; Tanaka et al., 1981) at the level of the pterygoid muscles Tanaka et al. (1981) have suggested that local anesthetics may interact with the Ca2+ -calmodulin complex and selectively inhibit the Ca2+-calmodulin enzyme activities.

It has recently been suggested that the inhibitory effects of local anesthetics in the activation of the intra cellular calcium messenger system may be part of the pharmacological mechanism, whereby local anesthetics participate in cellular activities. (Ogawa 1990). 
Experience has shown that it is necessary on average to perform these injections bilaterally into the infra temporal fossa once a week for eight weeks. 

General myoresolution
Chloremezanon or baclofen were prescribed with a view to obtaining myoresolution. Both local and general myoresolution resulted in a satisfactory relaxation of the mandible elevator muscles.


The emetic symptoms of the 161 patients subjected to arthrography can be summarized as followscan be summarized as follows :

- 25 patients suffere

- 90 patients suffered from nausea and no vomiting

- the remaining patients did not complain of these symptoms. 
Within two weeks generally, the nausea and vomiting had disappeared completely. The vomiting was the first symptom to be alleviated. Eight weeks of treatment were necessary before the other symptoms completely disappeared. The dislocation seemed to have no effect on the vomiting whether it was reducible or not.
A splint was placed on the mandible in some cases where neither the local or general myoresolution was sufficiently effective. This procedure is actually rarely used by us to treat nausea and vomiting but can often be necessary to deal with headache and neck pains. 
We have previously noted that, after the second local anesthesia into the both infra temporal fossa, near ( 8 mm) from Ovalis Foramen, the nausea and vomiting usually disappear. However, in some cases when a third injection is necessary, it is sometimes possible to observe an aggravation of all the symptoms after the injection, wich can list for 24 to 36 hours. The nausea and vomiting subsequently disapear completly after this episode. The agravation after the third injection is very well accepted by the patient if they are warned before treatment.

How are the links observed here between the masticatory system and nausea and vomiting to be accounted for ? Since the studies by Kerr (1962), it has been 
recognized that the trigeminal nerve is not the only source of sensory projections to the spinal nucleus of the trigeminal nerve. The Nucleus Tractus Solitarius (NTS) at the level of the obex, to which they convey messages from both the Area Postrema (AP) and peripheral afferents. The NTS is therefore a likely candidate as the site of interactions between the AP and peripheral afferent signals.

It has been clearly established on the basis of labeling experiments that vagal sensory projections extend to both sites of the AP and around neurons of the Dorsal Motor Nucleus (DMN). Kalia et al., (1980) have reported that the NTS receives information from both the AP and peripheral aferents, from wich they concluded that interactions may occur between this pathways, and tha AP stimulation may facilitate the effect of solitary tract activation.

The NTS is known to be the primary relay of the peripheral cardiovascular, respiratory and gastrointestinal apparatus (Berger , 1979 ; Ciriello et al., 1981 ; Jacquin et al., 1982) On the other hand, intense substance P-like immonureactivity (SPLI) was observed in fiber bundles coursing between the spinal nucleus on the trigeminal nerve (South et al. ,1986 ; Wen-Bin et al., 1991) and the ventro lateral nucleus of the solitary tract at the level of the area postrema.

Following unilaterally section of the trigeminal nerve, the SPLI-containing fiber bundles were absent ipsilaterally to the nerve section. These data indicated the presence of a trigeminal solitary projection which is composed of trigeminal sensory neurones containing substance P. 
These results suggest an anatomical route whereby substance P of trigeminal origine may modulate vagal or glossopharyngal sensory information ( Fig 1). According to Strand et al., ( 1991), substance P can induce behavioral nociceptive responses. (i.e. : biting). The continuation of this behavioural reponses may explain clenching.
During the day, these patients clenched their teeth quite moderately, whereas at night the force of the clenching was so strong that upon waking, the patients reported feeling fatigue and suffering from nausea and / or vomiting. The clenching played such a decisive role that the nausean vomiting disappeard completly in three patients who had been encouraged by concelling to control their own clenching.
Fig 1: Anatomical schematic A A diagram of the neurones projections of the cranial nerves and internuclear connectivity of the brainstem, drawn after Kerr (1962). Abbreviations : V2 Maxillary nerve ; V3 Mandibular nerve ; VIIint Facial nerve (nervus intermedius) ; IX Glossopharyngeal nerve ; X Vagus nerve; SPL:Subtance P like immunoreactivity
Via which pathway might dental afferents reach the area postrema ? The central projection targets of the periodontal mechanoreceptors are of two kinds (Hartmann et al., 1979 ; Van Willingen, 1986).
1 - The cell bodies of some dental afferents are located in the gasserian ganglion. Most of their central processes project to the spinal tract of the trigeminal nucleus (see figure 1), which consists of a pars oralis, a pars interpolaris, and a pars caudalis an extends from the pons to the C3 level.
On the other hand, Trub & Mei, (1991) have shown that periodontal mechanoreceptors project to the hypothalamus (VPM). Under these conditions, most of the periodontal mechanoreceptors are liable to activate the area postrema directly via the solitary tract and indirectly via the hypothalamus by the mean of the dorsal longitudinal tractus when clenching occurs. At the hypothalamic level, the dental aferences may be able to either enhance or reduce the activity oh hypothalamic cells. The aera postrema is known to receive abundant central projections from the parvocellular and paraventricular hypothalamic nuclei (Horst et al. 1984). The aim of our treatment was therefore to control the bruxism : if patients with cranio mandibular disorders could be prevented from clenching or grinding their teeth, it seems likely that their nausea and vomiting could be relieved. 
Bilateral injection of local anesthetic (lidocaine 3 %) into both infra temporal fossa seems to greatly inhibit the amount of proprioceptive and motor information conveyed to the mandibular elevator muscles when clenching occurs. Paradoxically, it is worth noting that the effects of the local anesthetic have been reported to last for five or seven days. It is therefore necessary to inject local anesthetic into both infra temporal fossa once a week for eight weeks.Incentally it was confirmed here that is rarely necessary to have recourse to splints in order to control the emetic symptoms.

The results of the present study support the hypothesis that the area postrema (AP) may interact with periodontal mechanoreceptors (bruxism) to modulate NTS neurone activity.

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Mechanisms and Control of Emesis. Eds A.L. Bianchi, I. Grélot, A.D. Miller, G.I. King. Colloque INSERM / John Libbey Eurotext. Ltd. © 1992, Vol.223, pp.51-58



Takemura M, Sugimoto T, Sakai A.(1987) Topographic organization of centralterminal region of different sensory branches of the rat mandibular nerve. Exp Neurol. Jun;96(3):540-57.

The central projection of primary neurons comprising the auriculotemporal nerve, cutaneous branch of the mylohyoid nerve, inferior alveolar nerve, mental nerve, lingual nerve, and buccal nerve was investigated using transganglionic transport of HRP in young rats. In view of the topographic organization of central projection fields, the nerves were divided into two groups; i.e., those projecting to the dorsolateral margin of the trigeminal nucleus principalis, subnucleus oralis, and interpolaris (the auriculotemporal, mylohyoid, and mental nerves) and those projecting more medially (the inferior alveolar, lingual, and buccal nerves). The former group of nerves projected more caudally than the latter in the medullary and spinal dorsal horn complex rostral to the 3rd cervical segment, in general. Furthermore, the latter group projected to the nucleus of the solitary tract and the supratrigeminal and paratrigeminal nuclei, whereas the other nerves did not. The data indicate the following points : Primary neurons innervating the intraoral structures terminate medial (in trigeminal nucleus principalis and subnucleus oralis) and ventral (in subnucleus interpolaris) to the terminal fields of those innervating the facial skin. Primary neurons innervating the intraoral structures project to the nucleus of the solitary tract and the supra- and paratrigeminal nuclei, whereas those innervating the facial skin do not. Primary neurons innervating the periphery of the face project to the spinal dorsal horn and those innervating the intra/perioral region project to medullary dorsal horn, though this segregation from the medulla to the 3rd cervical segment is relatively loose. Only those trigeminal primary neurons, whose receptive fields extend to or beyond the midline, project to the contralateral dorsal horn from the medulla to the 3rd cervical segment.



Bibliography :

Hartmann F (1992) Cranio-mandibular disorders inducing nausea and vomiting. In : Mechanisms and Control of Emesis (Bianchi AL, Grélot AD, Miller GI, King GI) (ed) Colloque INSERM/John Libbey Eurotext Ltd C: 51-8

Wen-Bin Z, Ji-Shud L, Hui -Li L (1991) SP-Like immuno reactivity in the primary trigeminal neurones projecting to the nucleus tractus solitarii. Brain Res 558: 87-89

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