Myofacial Pain Dysfunction Syndrome Research Articles

Prevalence of stress associated oral mucosal disorders among patients from Southern Rajasthan, India

Data on the prevalence of stress associated oral mucosal lesions/conditions such as Oral lichen planus, Apthous ulcers, Burning mouth syndrome, Headache, Xerostomia, Halitosis, Myofacial pain Dysfunction syndrome amongst population of Southern Rajasthan is of interest to dentists. Cross sectional study had been conducted on 5214 patients from 18-60 years age group who visited the Department of the Oral Medicine and Radiology, Pacific Dental College and Research Centre, Bedla, Udaipur. Findings such as burning of oral mucosa, presence of vesicles and ulcers, striation in oral cavity, limitation of jaw movement, muscular pain were assessed for the establishment of diagnosis. Prevalence of stress associated oral mucosal lesions/conditions like Oral lichen planus, Apthous ulcers, Burning mouth syndrome, Headache, Xerostomia, Halitosis, Myofacial pain Dysfunction syndrome was reported to be 12%, 17%, 3%, 21%, 6 %, 23 and 18% respectively. Besides stress management therapy, Professional consultation along with proper investigation and medicinal treatment is required

Etiological factors of temporomandibular joint disorders

The temporomandibular joint disorders are defined as a collective term embracinga number of clinical problems that involve the masticatory muscles, the TMJ andassociated structures. Myofacial pain dysfunction syndrome (MPDS) is the most common.functional disorder of TMJMany etiological factors have been blamed to produce pain and dysfunction of.TMJ such as stress, malocclusion and parafunctional habitsStress is thought to be responsible for hyperactivity of the muscles of mastication.which leads to muscle fatigue then muscle spasm and painThe purpose of this study was to determine the role of stress as an ctiological.)factor in (MPDSOne hundred dental students were used in this study and evaluated for havingMPDS. Another sample of one hundred persons from the general population were.evaluated in the same manner to be used as controlThe results of this study indicated that (55%) of participating students haveMPDS) because of the great amotmts of stress they are going through. While in control group there was only (7%).

New Avenue for Treatment of Dentinal Hypersensitivity Assisted with Tekscan a Diagnostic Tool

ABSTRACT Background: Occlusion is dynamic and plays an important role in the functioning of the stomatognathic system. Disturbance in one of the components of the stomatognathic system may result in hypersensitivity of teeth, orofacial pain, migraine, and temporomandibular joint (TMJ) disorders. Coronoplasty done using articulating paper is the conventional method for occlusal corrections. T-scan is a computerized occlusal analysis system that overcomes the limitations of articulating paper. Methods: Patients with Myofacial pain dysfunction syndrome (MPDS) having dentinal hypersensitivity were taken into consideration. The case series included three cases. A joint vibratory analysis (JVA) is performed using a JVA device to rule out any TMJ disorders. T-scan-assisted coronoplasty is performed. Patients are asked to score for dentinal hypersensitivity on the VAS scale pre and postoperative. Results: Occlusion and disocclusion time is reduced along with hyperactivity of the muscles after T-scan-assisted coronoplasty. There is a reduction in dentinal hypersensitivity postoperative. Conclusion: T-scan quantifies the forces and hence proved a boon in the field of dentistry. The present case series highlights coronoplasty assisted with a T-scan for diagnosis and treatment planning of hypersensitivity of teeth; hence it is the future of dentistry. Practical Implications: T-scan is a device that is assisted with electromyography. It projects the forces of mastication at every contact point of maxillary and mandibular teeth and reveals muscular hyperactivity. It can be used in MPDS patients with dental hypersensitivity due to occlusal discrepancy as it can guide elective coronoplasty relieving pain and dentinal hypersensitivity.

The Impact of Mindfulness Meditation on the Psychosomatic Spectrum of Oral Diseases: Mapping the Evidence.

The psychological aspect of dis-ease, which is indeed a lack of ‘ease’ is generally overlooked in the management of myriad maladies that affect the human body. The concept of mindfulness meditation, which is an interesting hybrid born from the meditative discipline of the east and the intellectual discipline of the west is gaining attention in the past two decades for its benefits in the holistic development of individuals. When individuals with ailments are trained under therapists supervised by the clinicians, significant results can be seen in alleviating symptoms like pain, stress, anxiety and an improvement in the quality of life is observed. This review article focuses on the structure and basics of mindful meditation and the mechanisms of mindfulness and its positive effects on various diseases like lichen planus, urticaria, psoriasis, eczema, myofacial pain dysfunction syndrome, to name a few. There are various arenas within the discipline of oral and maxillofacial medicine where mindfulness-based techniques can be explored for its effectiveness in combating psychosomatic conditions. The article highlights the importance of holistic approach in treating diseases in which mindfulness meditation techniques play an important role.

The Etiopathogenesis of Myofacial Pain Dysfunction Syndrome

This article presents a review of revisiting the Etiopathogenesis of myofacial pain dysfunction syndrome.This article concentrates on the appropriate evaluation, causes and management of MPDS. Myofacial painis one of the significant and common reasons for the orofacial pain that originate from the myofacial triggerpoint. Patient with myofacial pain dysfunction syndrome also complains of a chronic musculoskeletal painon which pressure on a sensitive muscle or point cause pain.

Bio Electro Magnetic Energy Regulation (BEMER) therapy in myofascial pain dysfunction syndrome: A preliminary study

BackgroundMyofacial pain dysfunction syndrome (MPDS) is of the commonest form of orofacial pain encountered in the clinics. Though, many therapies have been suggested in the recent past, still the management of this condition remains a therapeutic problem. The search for newer, relatively safe and effective long term approach lead to the use of magnetic stimulation in pain modulation. Bio Electro Magnetic Energy Regulation is one such modality that has been studied in the musculoskeletal disorders. However, no studies in this regard have been explored in orofacial region. ObjectivesThe objective of the present study was to evaluate the efficacy of BEMER therapy as an adjuvant to relieve pain in myofascial pain dysfunction syndrome. Materials and methodsThe present randomized comparative study was on 40 patients who were diagnosed with Myofacial pain dysfunction syndrome(MPDS). They were grouped into two groups of 20 each. Group 1 patients were administered analgesic + muscle relaxants & Group 2 was receiving both analgesic + muscle relaxants with BEMER therapy. All the patients were evaluated for pain relief on visual analog scale (VAS) and the mouth opening (MO)was measured using digital vernier callipers. ResultsThe group 2 showed a significant improvement in the symptoms even after 2 months follow up. In group 2 the mean mouth opening was 45.60 ± 3.648(P < 0.05) and 45.50 ± 3.663(P < 0.05); the Mean VAS Score was 3.10 ± 0.912 and 2.90 ± 0.968(P < 0.05) after one month and after two months respectively. The independent t-test, was used for inferential statistics. ConclusionIt can be concluded from this study that Combined therapy proved to be more effective in providing long term symptomatic relief compared to conventional pharmacological therapy. BEMER as an adjuvant therapeutic modality proved to be beneficial in the management of MPDS.

Temporomandibular disorders in North Indian population visiting a tertiary care dental hospital.

Background:The terminology “temporomandibular disorders” (TMDs) encompasses a wide spectrum of conditions. Several hypothesized causes are occlusal disharmony, muscle hyperactivity, central pain mechanisms, psychological distress, and trauma. In day-to-day practice, TMDs had become more prevalent in Indian population due to changed dietary pattern and food habits, excessive stress of modern life, and other environmental causes. This study is an attempt to find the prevalence of TMDs in North Indian population.Aims:The present study is taken into account to determine the prevalence of TMDs on the basis of signs and symptoms based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).Materials and Methods:The present cross-sectional study was conducted in the Department of Oral Medicine and Radiology. A total of 1009 patients aged between 6 and 80 years with a mean age of 42.04 ± 16.8 years seeking dental treatment from January 2016 to June 2017 were included in the study. All the patients were screened for TMD sign and symptoms. The demographic data and the signs and symptoms of TMDs were recorded in designed structured questionnaires which were based on the RDC/TMD criteria.Results:The study population consisted of 1009 patients aged between 6 and 80 years. In the present study population, based on RDC/TMD criteria, the incidence of clicking sound (42.5%) was highest in TMD joint followed by deviation of mandible on mouth opening (40.8%), internal derangement (36.8%), myofacial pain dysfunction syndrome (33.7%), osteoarthritis (29.5%), crepitus (25.8%), joint tenderness (5.8%), and pain on mouth opening (4.8%).Conclusion:Clicking sound was the most common sign of TMD disorders in Indian population.

THE USE OF BOTULINUM TOXIN INJECTION IN THE MANAGEMENT OF MYOFASCIAL PAIN DYSFUNCTION SYNDROME

Objectives: To evaluate the short-term effect of the botulinum toxin, type A (BTX-A) injection for the treatment of myofascial pain dysfunction syndrome.Materials & Methods: Foueteen female patients suffering from myofascial pain dysfunction syndrome were included in this study. For all patients both the masseter and temporalis muscles were injected once with 20-30 Units of BTX-A respectively and followed up for three months. Follow up included clinical assessment of maximal inter-incisal opening, range of lateral movement and visual analogue scale for pain. Electromyography (EMG) images were ordered pre-operatively and at the end of 3 months’ period to quantify the changes in muscle activity. Results: Results of the present study showed resolution of pain in all patients upon completing the follow up period. Conclusion: Within the limits of this study BTX-A can be used effectively for the treatment of myofacial pain dysfunction syndrome.

Effect of high-frequency bio-oxidative ozone therapy for masticatory muscle pain: a double-blind randomised clinical trial.

To evaluate the effect of bio-oxidative ozone application at the points of greatest pain in patients with chronic masticatory muscle pain. A total number of 40 (40 women, with a mean age of 31·7) were selected after the diagnosis of myofacial pain dysfunction syndrome according to the Research Diagnostic Criteria for temporomandibular disorder (RDC/TMD). The patients were randomly divided into two groups: patients received the ozone therapy at the point of greatest pain, ozone group (OG; n=20); patients received the sham ozone therapy at the point of greatest pain, placebo group (PG; n=20). Ozone and placebo were applied three times per week, for a total of six sessions. Mandibular movements were examined, masticator muscles tenderness were assessed and pressure pain threshold (PPT) values were obtained. Subjective pain levels were evaluated using visual analogue sale (VAS). These assessments were performed at baseline, 1month and 3months. Ozono therapy decreased pain intensity and increased PPT values significantly from baseline to 1month and 3months in OG compared with PG. PPTs of the temporal (OG=24·85±6·65, PG=20·65±5·43, P=0.035) and masseter (OG=19·03±6·42, PG= 14·23± 2·95, P=0.007) muscles at 3months of control (T2) were significantly higher in the OG group. PPT value of the lateral pole was also significantly higher at T2 in the OG group (OG=21·25±8·43, PG=15·35±4·18, P=0.012). Mandibular movements did not show significant differences between treatment groups except rightlateral excursion values at T2 (OG=8·90± 1·77, PG=6·85±2·41, P=0.003); however, OG demonstrated significantly better results over time. Overall improvements in VAS scores from baseline to 3months were OG 67·7%; PG 48·4%. Although ozone therapy can be accepted as an alternative treatment modality in the management of masticatory muscle pain, sham ozone therapy (placebo) showed significant improvements in the tested parameters.

Oral manifestations of stress-related disorders in the general population of Ludhiana

Introduction: Oral diseases associated with psychological disorders have long been known in medicine. Emotional as well as psychological factors may act as significant risk factors in the initiation and progression of oromucosal diseases. Aims and Objectives: The aim of this study was to determine a correlation between stress and development of certain oral conditions such as lichen planus, myofacial pain dysfunction syndrome, xerostomia, bruxism, aphthous ulcers, and burning mouth syndrome. Materials and Methods: An observational comparative study was conducted among patients reporting to the Department of Oral Medicine and Radiology. A total of 130 patients gave a positive history of oral lesions, out of which 62 were stress related and the other 68 patients served as the control group (oral lesions with no history of stress). All these patients were subjected to routine systemic and oral examination. The results obtained were statistically compared using P value, t-test, and Chi-square test. Results: It was found that lichen planus and burning mouth syndrome were more common in females and myofacial pain dysfunction syndrome was prevalent in males. Xerostomia was found to increase with age. Conclusion: It was concluded that, though the etiology of most oral lesions is not known, the role of stress and other psychogenic factors cannot be ruled out in their occurrence.

Assessment of tempromandibular joint space and condylar position in patients with myofacial pain dysfunction syndromes by using cone beam computed tomography

Background and objective: Joint space assessment and condylar relation in the glenoid fossa is considered as integral component of the clinical assessment of the patient with tempromandibular joint disorder. Any variant from normal tempromandibular joint may affect the diagnosis and management of the case. Methods: Thirty patients with unilateral myofacial pain dysfunction syndrome were included in this study (14 male and 16 female). Joint space analysis was performed by cone beam computed tomography for all patients. Analysis of data for joint spaces (anterior, middle, posterior, medial and lateral) was performed by using t-test. Results: The joint spaces and condyle positions in anterior, superior and posterior regions showed less joint space and statistically significant difference (P <0.05) from same joint space of normal side. No statistically significant differences were found in space value between middle and lateral condylar space of the diseased side and normal side of the patient. The joint spaces in normal sides were between 2 to 3.2 mm. Age and gender variations showed no statistical differences. Conclusion: The use of cone beam computed tomography for examination of tempromandibular joint space in patients with myofacial pain dysfunction syndrome give a good diagnostic criteria for affected side.

Comparison of the diagnostic accuracy of CBCT and conventional CT in detecting degenerative osseous changes of the TMJ: A systematic review

Temporomandibular joint (TMJ) disorders are a group of conditions that cause pain and dysfunction in the jaw joint and muscles that control jaw movement. According to the Research Diagnostic Criteria (RDC/TMD), temporomandibular disorders (TMDs) may be classified into three different groups: a) myofacial pain dysfunction syndrome (MPDS), b) internal derangement, and c) arthritis. Complicated anatomy of the TMJ was the reason for developing standardized radiographic techniques to diagnose TMDs. The introduction of computed tomography (CT) in the diagnosis of TMJ disorders enabled much better delineation of anatomical structures of the joint due to lack of tissue superposition. Cone beam CT (CBCT) is the latest imaging modality for craniofacial deformities, with a lesser radiation exposure and cheaper cost when compared to CT. A systematic literature search was done to identify articles describing degenerative osseous changes of the TMJ using CBCT and conventional CT. Electronic search of scientific papers was carried out in PubMed (MeSH), ScienceDirect, and Cochrane databases using specific keywords. In this systematic review, all the selected articles demonstrate the role of CBCT and CT in diagnosing the degenerative osseous changes of the TMJ. The studies included in the review suggested that CT has been the method of choice to assess the TMJ dynamics and contours of the cortical bone.

Prevalence of temporomandibular disorders in Chennai population

Objective: This study aimed to determine the prevalence of temporomandibular disorders (TMDs) in Chennai city population. Materials and Methods: To obtain a representative sample, a house-to-house survey was conducted in three zones of Chennai and a total of 4197 individuals were randomly selected for the study. Among 4197 individuals, 1158 were excluded from the study, based on the exclusion criteria. Finally, a total of 3039 individuals were included in the study population. Results: More than half of the study sample (53.7%) in the present study had one or more clinical signs and symptoms of TMD. Deviation of mandible on mouth opening (42.1%) and clicking sound (38.6%) made up the highest percentage. Females aged 18 years and older reported higher prevalence of TMD signs and symptoms than men. However, these differences were not significant for all signs and symptoms in all age groups. Prevalence of TMD was reported in this study according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) system of classification, and myofacial pain dysfunction syndrome (MPDS) was reported in 0.8% of the population, internal derangement in 38.3%, and osteoarthritis in 14.6% of the population. Conclusion: Our study, in comparison to other prevalence studies, had a higher sample size and was representative of a cross section of the population. The results of this study show that a significant percentage of the population has signs of TMDs and there are chances that they may develop symptoms of TMDs. Further studies are needed for early identification and initiation of preventive measures which could prevent TMDs progressing to advanced stages where management becomes difficult.

Poster 95: Effect of Progressive Muscle Relaxation Therapy on Improving Signs and Symptoms of Patients With Myofacial Pain Dysfunction Syndrome

Poster 95: Effect of Progressive Muscle Relaxation Therapy on Improving Signs and Symptoms of Patients With Myofacial Pain Dysfunction Syndrome

Evaluation of certain dentofacial characteristics as predisposing factors in patients with myofacial pain dysfunction syndrome.

Though a multifactorial etiology has been comprehensively documented in the literature over the years for temporomandibular joint (TMJ) disorder, none of the theories give a total explanation of all aspects of the syndrome. The aim of this study was to evaluate face form and certain occlusal parameters as relevant factors in the degree of dysfunction of the Temporomandibular joint. One hundred and three patients suffering from TMJ dysfunction attending the Out Patient Department of Dr R. Ahmed Dental College over a period of 2years were clinically examined and subsequently tabulated and compared with the degree of dysfunction to analyze any correlation between them. The data were statistically analyzed by the student t test and χ(2) test to assess the significance of the dysfunction in relation to the various parameters examined. The study indicated a positive relationship between the degree of dysfunction of the TMJ to the face form and certain other attributes.

Low-level laser therapy and myofacial pain dysfunction syndrome: a randomized controlled clinical trial

Myofacial pain dysfunction syndrome (MPDS) is the most common reason for pain and limited function of the masticatory system. The effects of low-level lasers (LLLs) for controlling the discomfort of patients are investigated frequently. However, the aim of this study was to evaluate the efficacy of a particular source producing 660 nm and 890 nm wavelengths that was recommended to reduce of the pain in the masticatory muscles. This was a double-blind and placebo-controlled trial. Sixteen MPDS patients were randomly divided into two groups. For the laser group, two diode laser probes (660 nm (nanometers), 6.2 J/cm(2), 6 min, continuous wave, and 890 nm, 1 J/cm(2) (joules per square centimetre), 10 min, 1,500 Hz (Hertz)) were used on the painful muscles. For the control group, the treatment was similar, but the patients were not irradiated. Treatment was given twice a week for 3 weeks. The amount of patient pain was recorded at four time periods (before and immediately after treatment, 1 week after, and on the day of complete pain relief). A visual analog scale (VAS) was selected as the method of pain measurement. Repeated-measures analysis of variance (ANOVA), the t-test and the paired t-test were used to analyze the data. In each group the reduction of pain before and after the treatment was meaningful, but, between the two groups, low-level laser therapy (LLLT) was more effective (P = 0.031) According to this study, this type of LLLT was the effective treatment for pain reduction in MPDS patients.

Psychosocial stressors in oral lichen planus

Psychosomatic factors and their association with dermatological disorders are well recognized, yet their importance in oral lichen planus (OLP) is still debated. This study was done to determine the importance of psychosocial stressors in patients with OLP. An analytical age-sex matched double controlled study. Stratified serial random sampling was done for sample selection. The experimental group consisted of biopsy proven OLP subjects (n = 41), negative control consisted of apparently healthy general Out Patient Department (OPD) patients (n = 73) and positive controls were patients with burning mouth syndrome, atypical facial pain and myofacial pain dysfunction syndrome (n = 36). The General Health Questionnaire-version 28 (GHQ-28) and the Hospital Anxiety and Depression Scale (HADS) were used to evaluate psychosocial stressors in terms of stress, anxiety and depression respectively. The OLP patients had significantly higher stress (Z = 4.331; p < 0.05, significant), anxiety (Z = 4.260; p < 0.05, significant) and depression levels (Z = 4.942; p < 0.05, significant) than the negative controls when measured by GHQ and HADS respectively. Similar findings were noted between the two control groups, with higher stress (Z = 5.784; p < 0.05, significant), anxiety (Z = 6.416; p < 0.05, significant), and depression (Z = 4.841; p < 0.05, significant) levels in the positive control group. However, differences in stress (Z = 2.0416; p > 0.05, non-significant), anxiety (Z = 1.681; p > 0.05, non-significant) and depression levels (Z = 0.195; p > 0.05, non-significant) were found to be non-significant between OLP and positive control. Significantly higher stress, anxiety and depression levels were found in the OLP and positive control than the general population. No significant difference was noted between the OLP and the positive controls (in which psychosocial stressors are the sole etiology). These suggest that psychological stressors play an important role in the causation of OLP. It may be further hypothesized that these stressors form a starting point for the initiation of various autoimmune reactions, which have been shown to be contributory to the pathogenesis of OLP. Further longitudinal studies need to be done globally before definitive conclusions can be drawn.

Stabilisation splint therapy for temporomandibular pain dysfunction syndrome.

Pain dysfunction syndrome (PDS) is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromylagia, TMJ dysfunction syndrome, myofacial pain dysfunction syndrome, craniomandibular dysfunction and myofacial pain dysfunction. The aetiology of PDS is multifactorial and many different therapies have been advocated. To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome. Electronic databases (including the Cochrane Oral Health Group's Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library Issue 2, 2003; MEDLINE (1966 to June 2001); EMBASE (1966 to June 2001)) were searched. Handsearching of relevant journals was undertaken and reference lists of included studies screened. Experts in the field were contacted to identify unpublished articles. There was no language restriction. Randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other active intervention. Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction. Discrepancies were discussed and a third reviewer consulted. The author of the primary study was contacted where necessary. The studies were grouped according to treatment type and duration of follow up. Twenty potentially relevant RCTs were identified. Eight trials were excluded leaving 12 RCTs for analysis. Stabilisation splint therapy was compared to: acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, non-occluding appliance and minimal/no treatment. There was no evidence of a statistically significant difference in the effectiveness of stabilisation splint therapy (SS) in reducing symptoms in patients with pain dysfunction syndrome compared with other active treatments. There is weak evidence to suggest that the use of SS for the treatment of PDS may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment. There is insufficient evidence either for or against the use of stabilisation splint therapy for the treatment of temporomandibular pain dysfunction syndrome. This review suggests the need for further, well conducted RCTs that pay attention to method of allocation, outcome assessment, large sample size, and enough duration of follow up. A standardisation of the outcomes of the treatment of PDS should be established in the RCTs.

Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome

The successful management of patients with MPD syndrome is dependent on establishing an accurate diagnosis and using proper therapy based on an understanding of the etiology of the disorder. Establishing an accurate diagnosis is accomplished by taking a careful history, doing a thorough examination, and having a knowledge of the various other conditions that can produce signs and symptoms similar to those of MPD syndrome. Using proper therapy is related to recognition that MPD syndrome is a stress-induced psychophysiologic disease originating in the muscles of mastication and not an organic disease arising in the temporomandibular joint. Thus, therapy should be directed at reducing stress, relaxing tense jaw muscles, and creating an awareness by the patient of the causes of the problem, rather than at analyzing occlusion, measuring joint spaces, and producing irreversible structural changes in the dentition and the articulation. Because good results can be achieved with these uncomplicated, reversible forms of therapy, 31, 32 it is important that the clinician does not succumb to an unproven fad or use of an irreversible procedure that will not achieve better results.

Psychometric profiles and facial pain

The myofacial pain-dysfunction syndrome and atypical facial pain are the most prevalent chronic pain disorders of the facial region. Previously, the myofacial pain-dysfunction syndrome included all TMJ/masticatory muscle pain, jaw dysfunction, and joint clicking. We have segregated two major subgroups subsumed within this diagnostic classification and have assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Significant age and personality differences were uncovered when these subpopulations were compared to subjects with atypical facial pain (AFP). Both MFP and TMJID groups are relatively homologous, involving younger persons than AFP subjects. Alternatively, when MFP, TMJID, and AFP subjects were compared for differences in MMPI psychometric scales, MFP and AFP subjects exhibited significantly higher scores, particularly for hypochondriasis, depression, and hysteria, than did TMJID subjects. It is concluded that subcategorization of myofascial pain-dysfunction patients into a myogenic pain group and a TMJ internal derangement group is justified on the basis of psychometric differences. Furthermore, psychopathologic factors are more significant among MFP and AFP subjects than among TMJID patients.