[Pharmacologic therapy of cranio-cervico-mandibular disorders. Review of the literature]

The recommended treatments of craniomandibular disorders (CMD) are drug therapy, physiotherapy, relaxation procedures, occlusal therapy with and without splint. The purpose of this study is to carry out a survey of the literature on drug therapy in patients affected by CMD. It is essential to recognize the cause of pain (muscular or articular) and the phase of disorder (acute or chronic) in order to establish an adequate pharmacological protocol for each type of CMD. Non-steroidal anti-inflammatory drugs (NSAID) are generally accepted for treatment of internal derangement and myofacial pain, sometimes in association with benzodiazepine.

Intra-articular injection of hyaluronic acid reduces total amounts of leukotriene C4, 6-keto-prostaglandin F1alpha, prostaglandin F2alpha and interleukin-1beta in synovial fluid of patients with internal derangement in disorders of the temporomandibular joint

This prospective randomised study was designed to assess the effect of an intra-articular injection of sodium hyarulonate on internal derangement in disorders of the temporomandibular joint. Fifteen patients (4 men, 11 women, mean (SEM) age 33(3) years) with unilateral internal derangement of the temporomandibular joint without radiographic evidence of the condylar degeneration who were randomly allocated to have arachidonic acid metabolites (n = 9) or cytokines (n = 6) measured in synovial fluid. The preauricular area was disinfected and anaesthetised locally with 1% lignocaine hydrochloride. Synovial fluid was collected by rinsing the joint with saline 5 ml. Sodium hyaluronate 1 ml (10 mg) was then injected into the superior compartment of the temporomandibular joint. The treatment was repeated after two weeks. The effects of sodium hyaluronate on total amounts of arachidonic acid metabolites and cytokines and on symptoms was measured. Injection of sodium hyaluronate caused significant reductions in the mean (SEM) of total amounts of leukotriene C4 (4.68 (2.27) to 0.48 (0.24) ng/joint), 6-keto-prostaglandin F1alpha (12.12 (2.78) to 5.19 (1.90) ng/joint), prostaglandin F2alpha (12.63 (5.51) to 4.21 (2.20) ng/joint), and interleukin-1beta (100.5 (14.2) to 50.8 (13.9) pg/joint), respectively (P<0.05 in each case). The mean (SEM) pain score was significantly reduced from 2.56 (0.18) to 0.89 (0.26) (P<0.01), the noise score from 2.18 (0.23) to 1.18 (0.18) (P<0.05), and degree of mouth opening from 28.2 (2.5) to 34.9 (2.0) mm (P<0.01). However, no improvement in symptoms was recorded in 1/9, 5/11, and 1/9 patients, respectively. These findings suggest that inflammation plays a part in internal derangement of the temporomandibular joint, and injection of an anti-inflammatory substance may be beneficial to such patients.

Medical treatment of recurrent temporomandibular joint dislocation using botulinum toxin A

This paper describes a new technique for prophylactic treatment of recurrent mandibular dislocation using injection of botulinum toxin A (BtA) into the lateral pterygoid muscles. BtA temporarily weakens muscles by blocking acetylcholine release, and thus operates through a principle different from established treatments such as joint sclerosant therapy, eminectomy or Dautry's procedure. The patient suffered recurrent mandibular dislocations caused by tardive dystonia. We injected 75 mu BtA percutaneously into each lateral pterygoid muscle under electromyographic guidance. No further dislocations occurred over the subsequent 10 months, and follow-up continues. There were no immediate or delayed side effects. More experience is required before this becomes an established treatment. BtA is usually given in outpatients, and is less invasive or destructive than previous options. It may not be suitable if dislocation is due to lax ligaments or weak muscles. Operators must be aware that other BtA preparations require a different dose.

Treatment of recurrent dislocation of the temporomandibular joint with type A botulinum toxin

A case is reported of a 56-year-old woman who suffered from recurrent dislocations of the temporomandibular joint (TMJ) secondary to an exacerbated tetraspastic syndrome of multiple sclerosis. Following chemical denervation of the masseter and pterygoid muscles with injections of type A botulinum toxin, no further dislocations occurred for periods of up to four months. The treatment has been repeated five times. Some of the indications and possible adverse reactions to this therapy are discussed and comparisons made with other, conventional methods for managing recurrent dislocation of the TMJ.

The effect of hyaluronic acid on experimental temporomandibular joint osteoarthrosis in the sheep

PURPOSE

The purpose of this study was to test the effect of repeated injections of hyaluronic acid (HA) on the sheep model of osteoarthrotic temporomandibular joint (TMJ) disease.

MATERIALS AND METHODS

Bilateral osteoarthrosis (OA) was induced in the TMJs of six sheep. HA was injected into one joint on 7, 10, 14, 17, and 21 days postoperatively. Normal saline was injected into the contralateral joint. Three sheep were killed at 1 month and 3 at 3 months. The joints were removed and examined macroscopically and histologically. A special scoring system was applied following the modified Mankin's score to evaluate the histologic changes.

RESULTS

The control group showed severe osteoarthrotic changes in the condyle, deviation in form from normal morphology, and marked marrow fibrosis. The HA-treated group showed less deviation from normal condylar morphology. The histologic scores at 1 month were HA 12.6, control 24.2 (P < .001), and at 3 months were HA 6.9, control 18.9 (P < .001). There was a significant difference in osteoarthrotic changes between HA-treated and control TMJs, with the HA-treated TMJs having less severe changes.

CONCLUSION

Repeated intraarticular injections of HA into a sheep TMJ with experimentally induced OA minimizes the extent of osteoarthrotic change when compared with the control joint. Thus, HA may have a role in preventing the progression of TMJ OA.

Infectious temporomandibular joint disease in the horse: computed tomographic diagnosis and treatment of two cases

Diagnostic imaging and treatment of unilateral destructive temporomandibular joint disease in two horses is described and discussed. Computed tomography appeared to be the best imaging technique for these lesions. The disease can be followed by functional recovery after the infection has resolved.

[Neurogenic temporomandibular joint dislocation. Definition and therapy with botulinum toxin]

Dislocation of the temporomandibular joint results from trauma, articulation disorders and changes in the equilibrium of the masticatory muscles. Previous classifications were mostly oriented on the interrelationships between the anatomical positions of the dislocated articular surfaces, like luxation, subluxation and discuss luxation. Etiologically, a distinction is made between traumatic and non-traumatic dislocation. Dislocation of the temporomandibular joint is described as a complication of a number of neurological diseases. We report on a patient who suffered recurrent dislocations of the temporomandibular joint as a complication of multiple sclerosis and whose luxations were successfully treated with botulinum toxin, thus warranting the introduction of the term "neurogenic dislocation of the temporomandibular joint".

Temporomandibular joint iontophoresis: a double-blind randomized clinical trial

This double-blind study evaluated the short-term effect of iontophoretic delivery of dexamethasone on the signs and symptoms of temporomandibular disorders in patients who had concurrent temporomandibular joint disc displacement without reduction and capsulitis. Twenty-seven patients with this clinical diagnosis were randomized to one of three groups: treatment group (dexamethasone sodium phosphate and lidocaine hydrochloride); control group (lidocaine hydrochloride); and placebo group (pH-buffered saline). Pretreatment and posttreatment data included items to calculate Helkimo's Anamnestic Dysfunction index, Helkimo's Clinical Dysfunction index, the Symptom Severity Index, and the Craniomandibular Index (CMI). The CMI is composed of the Dysfunction index (DI) and Muscle index. Analysis of variance showed no baseline differences on these measures between the three groups. Pretreatment and posttreatment values were compared with the paired t tests. Posttreatment, the treatment group had an increased mean maximal active mandibular opening of 6 mm (P = .02), increased mean lateral excursion of 1.2 mm to the noninvolved side (P = .05), and reduced mean DI scores of 0.51 to 0.39 (P = .01); no statistically significant decrease in pain symptoms was reported. Analysis of variance showed a significant difference in the DI scores (P = .04) between groups from pretreatment to posttreatment, with the treatment group showing the greatest improvement in the DI scores relative to the other two groups. No other questionnaire items, exam items, or resultant indexes showed changes in any of the groups at P < or = .05. These results suggest that iontophoretic delivery of dexamethasone and lidocaine was effective in improving mandibular function, but not in reducing pain, in temporomandibular disorders patients who had concurrent temporomandibular joint capsulitis and disc displacement without reduction.

The effect on joint fluid concentration of neuropeptide Y by intra-articular injection of glucocorticoid in temporomandibular joint arthritis

Twenty-two patients (29 joints) with temporomandibular joint (TMJ) arthritis of specific or unspecific nature were given one intra-articular glucocorticoid (GC) injection. The effect on subjective symptoms and clinical signs in the craniomandibular system and on joint aspirate concentration of neuropeptide Y-like immunoreactivity (NPY-LI) was evaluated at follow-up visits 2-3 or 4-6 weeks after treatment. In the patients with specific inflammatory joint disease the treatment resulted in an improvement of symptoms and clinical signs and in a reduction in the TMJ level of NPY-LI 2-3 weeks after treatment. In the patients with unspecific inflammatory joint disease there was also an improvement in the clinical variables and a reduction in the NPY-LI level after 2-3 weeks, but not on a statistically significant level. The results of this study show that intra-articular GC treatment causes a short-term decrease of the TMJ fluid level of NPY-LI in patients with specific inflammatory joint disease, while symptoms and signs improve.

Temporomandibular disorders. 2. Non-surgical treatment

There are many treatment modalities for temporomandibular disorders (TMD), most of which are effective in controlling symptoms, at least in the short term. The non-surgical treatment of temporomandibular disorders continues to be the most effective way of managing over 80 per cent of patients who present with symptoms of temporomandibular pain and dysfunction. In this, the second article in the series, a general overview of the current non-surgical treatment strategies for TMD will be presented.

Pharmacologic considerations in the management of temporomandibular disorders

The management of patients with temporomandibular disorders may involve the use of a number of modalities, including pharmacotherapy. This manuscript provides an overview of the pharmacology of agents currently employed for this purpose, with an emphasis on the major drug group used, the non-steroidal anti-inflammatory drugs (NSAIDs). A brief discussion of opioid analgesics, tricyclic antidepressants, muscle relaxants, benzodiazepines, steroids, and local anaesthetics is also included, and guidelines for their use are suggested.

Use of Hylan G-F 20 for viscosupplementation of the temporomandibular joint for the management of osteoarthritis: a case report

Viscosupplementation is a relatively new treatment concept for restoring the normal rheologic properties of the osteoarthritic joint. It is most often used for the knee. This case report describes results that were achieved using viscosupplementation following conservative therapy for a patient with osteoarthritis of the temporomandibular joint. Further study in the use of these treatments is recommended.

Use of superoxide dismutase (SOD) in patients with temporomandibular joint dysfunction--a preliminary study

The aim of this preliminary study was to investigate and assess the effect of intra-articular injection of superoxide dismutase (SOD) in patients with temporomandibular joint (TMJ) dysfunction who had not responded to conservative therapy in a first study. Thirty joints in 29 patients were studied. The results showed that intra-articular injection of superoxide dismutase was effective in 25 joints (83%). It was concluded that intra-articular injection of superoxide dismutase may be an alternative therapy for patients with TMJ dysfunction who fail to respond to conservative treatment.

Evaluation of iontophoretically applied dexamethasone for painful pathologic temporomandibular joints

The effects of iontophoretically applied dexamethasone in a lidocaine vehicle were compared with those of saline placebo in 53 patients with one of three diagnoses of painful temporomandibular joint pathologic conditions: disk displacement with reduction, disk displacement without reduction, and osteoarthritis. Both dexamethasone and the saline placebo produced a significant reduction in pain scores from baseline levels after the first two of three treatments. There were no observed differences, however, in pain report or mandibular range of motion between the dexamethasone and placebo groups. A trend for pain relief was noted in the subgroup that received dexamethasone with a diagnosis of osteoarthritis. Results may reflect varying degrees of inflammation or central nervous system hyperexcitability, or both, in this heterogeneous study sample. Potential confounding variables were lack of knowledge of actual drug penetration, the effects of electric current transmitted by the iontophoresor, and pain reduction caused by cyclic fluctuations in symptoms. These data suggest that iontophoretically applied dexamethasone is no more effective than saline placebo in providing pain relief in patients with temporomandibular joint pain.

A technique for the accurate administration of corticosteroids in the temporomandibular joint

A new technique for intra-articular injection of a corticosteroid in the temporomandibular joint (TMJ) is presented. The corticosteroid is mixed with contrast medium and the administration visualized and controlled using fluoroscopy. When superior and inferior joint spaces have been filled and the soft tissues of the joint have been identified in the fluoroscopic image, additional corticosteroid can be administered to selected sites within the TMJ.

Use of sodium hyaluronate in treating temporomandibular joint disorders: a randomized, double-blind, placebo-controlled clinical trial

This study assessed the efficacy of high-molecular-weight sodium hyaluronate as a treatment for certain intracapsular temporomandibular joint (TMJ) disorders. One hundred twenty-one patients were studied at three test sites using a randomized, double-blind, placebo-controlled experimental design. Patients were selected on the basis of 1) confirmed diagnosis of either degenerative joint disease (DJD), reducing displaced disc (DDR), or nonreducing displaced disc (DDN); 2) nonresponsiveness to nonsurgical therapies; and 3) severe dysfunction as established by the Helkimo indices (HI), visual analog scales (VASs), and physical measurements of joint movement and joint noise (arthrophonometry [APM]). Subjects received a unilateral upper joint space injection of either 1) 1% sodium hyaluronate in physiologic saline (MedChem Products, Woburn, MA) or 2) USP physiologic saline. Clinical evaluations were performed using HI, VAS, and APM at weekly intervals for the first month and then at monthly intervals up to 6 months postinjection. Statistical analyses for both categorical and continuous variables were performed for each diagnostic category at each examination interval. For DJD, no difference in outcome was seen between treatment groups. For DDN, significant between-group differences were seen through 1 month; however, beyond this time point, the number of DDN patients was insufficient to draw meaningful conclusions concerning efficacy. For DDR, statistically significant within-group and between-group improvement in all three measures (HI, VAS, APM) was seen for the hyaluronate group compared to the saline group throughout the 6-month test period. At the month-2 and month-3 examination intervals, twice as many patients treated with hyaluronate (90%) showed improvement compared to patients given placebo. Further, only 3% of patients with DDR who were treated with hyaluronate relapsed compared with 31% of patients with DDR given placebo.

Pressurized infusion of sodium hyaluronate for closed lock of the temporomandibular joint. Part I: A case study

Patients with temporomandibular joint disorders (TMD) report a myriad of problems including headaches, facial pain, limited mouth opening capacity, and clicking and/or grating sounds from the temporomandibular joints. Although conservative therapy with an occlusal splint can bring relief for many of these patients, a small number of subjects must be treated by means of surgical procedures. Direct injections of either air or fluids (saline, local anesthetic, corticosteroid, hyaluronate) into the superior and/or inferior temporomandibular joint (TMJ) cavities have gained popularity. The injection of a local anesthetic and hyaluronic acid can provide relief for patients with persistent, painful nontranslatory closed-lock conditions of the TMJs. As documented through objective electronic and computer-enhanced measurements, this case report describes the effect of sodium hyaluronate on a closed lock condition of the TMJ. This case report explains the methodology employed for a larger group of closed lock patients treated and monitored for over one year. The results of that larger group will be reported at a later time after long-term efficacy is confirmed.

Temporomandibular arthritis in familial Mediterranean fever

Temporomandibular joint arthritis is a rare manifestation of familial Mediterranean fever and should be considered in patients of Mediterranean origin. Recently we treated four patients suffering from this condition, and intra-articular corticosteroid injection resulted in rapid resolution of the pain and disability in two. Computed tomography confirmed the usefulness of this therapeutic modality.

Effect of ibuprofen on the healing and remodeling of bone and articular cartilage in the rabbit temporomandibular joint

The purpose of this study was to determine the effect of ibuprofen on the healing and remodeling of bone and cartilage in the temporomandibular joint of the rabbit. Forty-two rabbits were operated on to create a groove and a hole in the articular surface of both the right and left mandibular condyles. Following surgery, the animals were divided into three groups. Group A (12 rabbits) was used as a control and the animals did not receive any medication. Group B (15 rabbits) was given a daily dose of 17 mg/kg of ibuprofen. Group C (15 rabbits) was given a daily dose of 34 mg/kg of ibuprofen. All animals were killed after 4 weeks. The 84 condyles were examined clinically and histologically. Statistical analysis showed a highly significant difference in the healing of bone and cartilage between groups A and C (P less than .01) and a significant difference between groups A and B (P less than .05). The results of this study indicate that ibuprofen has an adverse effect on the healing of bone and cartilage in the temporomandibular joint of the rabbit.

Managing TMD patients: initial therapy is the key

It has been the intention of this brief paper to help dentists respond quickly and effectively to patients with TMD. (In lieu of a detailed bibliography, a brief list of articles and books that deal with diagnosis and therapy for TMD follows.) Several present actual guidelines for practice, while others discuss concepts in greater detail. Knowing how to help these troubled patients by using contemporary basic principles of pain management should make every practicing dentist feel a well-deserved sense of fulfillment.

A comparative study of three therapeutic modalities in a temporomandibular disorder (TMD) population

A comparative study of three treatment modalities, pharmacologic, occlusal appliance, and their combined use, was conducted to test their therapeutic efficacy on 61 temporomandibular disorder (TMD) patients. Alprazolam (Xanax) was used for the pharmacologic treatment; the occlusal appliance therapy consisted of a flat maxillary stabilization splint. Of the 61 patients, 19 received Alprazolam, 30 received occlusal appliance therapy, and 12 received combined therapy. Subjects were examined at two-week intervals for two months. Only 42 patients attended all follow-up visits. Eight parameters were studied: severity of pain, periodicity of pain, self-evaluated stress, muscle sensitivity to palpation, joint sensitivity to palpation, joint noises, limitation of opening, and limitation of lateral movement. No significant difference was found between the treatment modalities for most of the parameters. All three proved to be effective. Alprazolam increased the restricted mandibular movement, was least effective on joint sensitivity to palpation, and had no effect on joint noises. The combined treatment approach not only failed to prove superior to the other treatments, but showed less improvement in some parameters, possibly due to the small sample.

Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening

Seventeen patients complaining of suddenly occurring, severe, and persistent limited mouth opening were treated by irrigation of the upper compartment of the affected temporomandibular joint with lactated Ringer's solution. This simple treatment was found to be highly effective in reestablishing normal opening and relieving pain for a follow-up period of 4 to 14 months.

Pharmacologic management of temporomandibular joint disorders and chronic head and neck pain

One goal of pharmacology is to break a cycle of pain and spasms. In this cycle, pain leads to muscle spasms, and spasms lead to pain with no physiologic feedback control occurring. A second goal is to break another interacting cycle of pain and inflammation. In this cycle, pain mediators can lead to inflammation and the inflammation itself can contribute to pain. The two cycles perpetuate each other because they have many interacting factors in common. Drugs are useful either alone or to supplement other forms of therapy that can break the pain/spasm cycle, as well as the pain/inflammation cycle. This article discusses the many types of drugs available to the clinician today. Although the original version of this article was published by the first author in 1973, the number of new drugs (including some new classes of agents) and newer concepts of pain that have been introduced have required further updating.

Treatment with intravenous colchicine

This article studies 27 patients with resistant temporomandibular related symptomatology. It evaluates them comparing both their dental and medical diagnosis after the treatment with intravenous and oral colchicine. Modern medicine has used this drug in the treatment of gouty arthritis. It is, however, the oldest medication used in recorded history. Colchicine is a potent drug with potential side effects. Intravenous colchicine's major complication is the possible painful chemical burn to the injection site which may occur if the drug extravasates from the vein.

Review of oral skeletal muscle relaxants for the craniomandibular disorder (CMD) practitioner

The presence of acute or chronic muscle pain and muscle spasm is a common finding in the treatment of craniomandibular disorders. A review of the literature on the centrally acting oral skeletal muscle relaxants is presented to assist the practitioner in treating CMD. The pharmacology, pharmacokinetics, metabolism, adverse reactions and available dosage forms of the skeletal muscle relaxants are discussed. The agents reviewed are carisoprodol, methocarbamol, chlorphenesin carbamate, metaxalone, chloroxazone, orphenadrine citrate, diazepam, and cyclobenzaprine. Their mechanisms are not well defined. Most act via selective inhibition of polysynaptic pathways in the central nervous system. Most evidence for their efficacy is based on subjective responses and there is question as to the adequacy of the clinical studies to date. Based on the data all of the relaxants (possibly excepting diazepam) are better than placebo based on subjective analyses. Although combinations with analgesics provide better symptom relief, no superiority over analgesics exists. No skeletal relaxant has been shown to be superior over any other oral relaxant. Based on recent clinical suspicions, further study of multiple pharmacologic effects of newer agents is indicated.

Iontophoresis: an effective modality for the treatment of inflammatory disorders of the temporomandibular joint and myofascial pain

The use of the iontophoresis modality for driving medications through the skin for treatment of certain TM dysfunction and myofascial pain dysfunction syndrome was first suggested by Gangarosa and Mahan in 1982. This paper introduces the iontophoresis technique for treatment of inflammatory and myofascial disorders of the craniomandibular system. The historical aspects of iontophoresis in medicine and dentistry is reviewed. As an aid to understanding the clinical applications of this method, a review of diagnostic classification of temporomandibular disorders and an in-depth review of the role of the inflammatory process are provided. The effect of inflammation on the synovial/lymphatic system is detailed. Reference is made to the advantages of iontophoresis over hypodermic injection. The basis materials and methods of use of the modality are shown along with a protocol for patient treatment. Several case studies are discussed with clinical observations given.

Utilization and mechanism of action of tricyclic antidepressants in the treatment of chronic facial pain: a review of the literature

Tricyclic antidepressants show promise in the treatment of chronic facial pain. The antinociceptive activity of this class of drugs appears to be independent of any antidepressant effects. An hypothesis is proposed that tricyclics antidepressants activate a descending serotonergic (5-HT1) antinociceptive pathway which in turn influences endogenous opioids. This antinociceptive pathway appears to utilize an endogenous pain modulation system. Future studies may demonstrate the operative mechanisms of action and open understanding as to etiologic factors.

[Results of treatment with ionophoresis of posttraumatic changes of temporomandibular joints with an apparatus of own design]

The authors used ionophoresis applied with an apparatus of own design in 32 patients with posttraumatic changes in the temporomandibular joints. In 24 cases xylocaine and in 8 cases hydrocortisone were used. In 27 cases disappearance of pain was achieved and complications were not observed. The apparatus of own design was applied also for analgesia for operations on the middle ear through the external meatus, and in the treatment of ear buzzing and otalgia of unknown origin.

Long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint arthritis

The long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid (betamethasone) was compared in a sample of 24 patients who had pain and tenderness to palpation in the temporomandibular joint (TMJ arthritis) of at least six months duration, and who had not responded to conservative treatment. The two drugs were randomly allocated to the patients. The drugs, 0.5 ml, were injected twice into the superior joint compartment of the TMJ with a two-week interval between injections. The effect on subjective symptoms, clinical signs, and bite force was assessed. At the one and two-year follow-ups both the hyaluronate-and the corticosteroid-group had significantly reduced subjective symptoms as well as clinical signs, and the maximum voluntary bite force was significantly increased. The differences in effect between treatments were not statistically significant. It was concluded that both drugs have a significant long-term effect on chronic arthritis of the TMJ and that either of the drugs can be helpful; however, sodium hyaluronate might be the best alternative due to the least risk for side effects.

Treatment of an acute anterior disk displacement in the temporomandibular joint. A case report

The purpose of this case report is to describe the effects of a home exercise program and iontophoretic delivery of an anti-inflammatory agent and an anesthetic in the treatment of a patient with an acute internal derangement of the temporomandibular joint (TMJ). A 71-year-old woman was referred to physical therapy for treatment of an acute anterior displacement of the disk in the TMJ. She received two treatments consisting of iontophoretic delivery of dexamethasone sodium phosphate and lidocaine hydrochloride, and a home exercise program was prescribed. Clinical signs and symptoms were reduced after the first treatment and continued to abate during the course of treatment. Six weeks after treatment, her jaw range of motion remained within normal limits. She also reported being pain free and having resumed eating her regular diet.

Therapeutic injection of the temporomandibular joint

A simplified technique for a therapeutic injection of the temporomandibular joint has been presented. We have emphasized diagnosis of the condition, as well as indications and contraindications. If the injection is used where indicated, the results are quite successful. Since this technique is inherently less demanding than those so far described, it may overcome the reluctance of dentists to inject the TMJ and thereby make certain cases more responsive to treatment.

Psychogenic facial pain: presentation and treatment

An account is given of a two-centre controlled clinical trial to assess the efficacy of dothiepin (Prothiaden) against placebo and a soft bite-guard in the treatment of psychogenic facial pain. The results confirm the superiority of the dothiepin to placebo in achieving pain relief, but show no benefit from the use of mechanical treatment. Short-term relapse of pain which occurred in the follow-up period was not associated with recurrence of psychiatric symptoms but appeared to be directly related to withdrawal of dothiepin.