The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial

Masseter muscle sonographic features as indices for evaluating efficacy of massage treatment

OBJECTIVE

The aim of this study was to clarify the sonographic features of the masseter muscle as indices for judging the efficacy of massage treatment.

STUDY DESIGN

Fifteen patients with temporomandibular disorder (10 with unilateral and 5 with bilateral muscle pain) underwent massage treatment alternately on the bilateral masseter and temporal muscles with an oral rehabilitation robot. Sonography was performed before and after treatment, and the masseter thickness and existence of anechoic areas were evaluated.

RESULTS

The thickness on the symptomatic side in the unilateral group significantly decreased after treatment. Anechoic areas were shown in 20 muscles (66.7%) before treatment, and disappeared or were reduced in size in 17 muscles (85.0%) after treatment. The pretreatment thickness was significantly related to visual analog scale (VAS) scores regarding posttreatment muscle pain and massage impression. The existence of anechoic areas was relevant to VAS scores regarding muscle pain.

CONCLUSION

Masseter thickness and existence of anechoic areas might be related to the therapeutic efficacy regarding muscle pain.

Immediate effect of the resilient splint evaluated using surface electromyography in patients with TMD

The aim of this study was to analyze the immediate effect of resilient splints through surface electromyography testing and to compare the findings with the electromyographic profiles of asymptomatic subjects. The participants were 30 subjects, 15 patients with TMD (TMD Group) and 15 healthy subjects (Control Group), classified according to Research Diagnostic Criteria (RDC/TMD) Axis I. A resilient occlusal splint was made for each patient in the TMD Group from two mm thick silicon to cover all teeth. The EMG examination was performed before and immediately after installing the splint. Three tests were performed as follows: 1. Maximum Voluntary Contraction (MVC) using cotton rolls (standards test); 2. MVC in maximal intercuspation position; and 3. MVC with the splint in position. The EMG signal was recorded for five seconds. EMG indices were calculated to assess muscle symmetry, jaw torque, and impact. There was a statistically significant difference when comparing the results among the study groups. The symmetry index values in the Control Group were higher than the TMD Initial Group and similar to the TMD Group after the installation of the splint. The index values of torque were higher in TMD Initial Group when compared with the Controls. Impact values were lower than normal values in the TMD Initial Group and restored upon installation of the splint. The resilient occlusal splints may be used as complementary or adjunctive treatment of temporomandibular disorders.

Possíveis fatores etiológicos para desordens temporomandibulares de origem articular com implicações para diagnóstico e tratamento

Os fatores envolvidos na etiologia, diagnóstico e tratamento das desordens temporomandibulares (DTM) de origem articular foram revisados. Critérios específicos de inclusão e exclusão para o diagnóstico de DTM são essenciais, mas apresentam utilidade limitada. Atualmente, os Critérios Diagnósticos de Pesquisa para Desordem Temporomandibular (RDC/TMD) oferecem a melhor classificação baseada em evidências para os subgrupos mais comuns de DTM. O RDC/TMD inclui não apenas métodos para a classificação diagnóstica física, presentes em seu Eixo I, mas ao mesmo tempo métodos para avaliar a intensidade e a severidade da dor crônica e os níveis de sintomas depressivos e físicos não-específicos, presentes em seu Eixo II. Embora historicamente as más oclusões tenham sido consideradas como fatores de risco para o desenvolvimento das DTM, incluindo as predominantemente articulares, em muitos casos a associação estabelecida entre essas variáveis parece ter tomado direção oposta. No que diz respeito aos desarranjos internos da ATM, os resultados de estudos prévios sobre a redução induzida do ramo mandibular, secundária ao deslocamento anterior do disco articular, indicam que o reposicionamento do disco deslocado em crianças ou adolescentes jovens pode fazer mais sentido do que previamente imaginado. O uso terapêutico de suplementos alimentares, como o sulfato de glicosamina, parece uma alternativa segura ao uso dos medicamentos anti-inflamatórios normalmente utilizados para controlar a dor relacionada à osteoartrite da articulação temporomandibular (ATM), embora a evidência em torno de sua eficácia para a maioria dos pacientes de DTM não tenha sido completamente estabelecida.

Psychometric properties of the modified Symptom Severity Index (SSI)

The psychometric properties of the modified Symptom Severity Index were investigated to assess the relationships among dimensions of pain in temporomandibular disorders (TMD). The 15-item instrument is composed of ordinal scales assessing five pain dimensions (intensity, frequency, duration, unpleasantness and difficulty to endure) as experienced in three locations (temple, temporomandibular joint (TMJ), masseter). In 108 closed-lock subjects, Cronbach's alpha was used to measure internal consistency resulting in 31 of the 105 pair-wise comparisons >or=0.71. Multilevel exploratory factor analysis was used to assess dimensionality between items. Two factors emerged, termed temple pain and jaw pain. The jaw pain factor comprised the TMJ and masseter locations, indicating that subjects did not differentiate between these two locations. With further analysis, the jaw pain factor could be separated into temporal aspects of pain (frequency, duration) and affective dimensions (intensity, unpleasantness, endurability). Temple pain could not be further reduced; this may have been influenced by concurrent orofacial pains such as headache. Internal consistency was high, with alphas >or=0.92 for scales associated with all factors. Excellent test-retest reliability was found for repeat testing at 2-48 h in 55 subjects (Intra-class correlation coefficients = 0.97, 95%CI 0.96-0.99). In conclusion, the modified Symptom Severity Index has excellent psychometric properties for use as an instrument to measure pain in subjects with TMD. The most important characteristic of this pain is location, while the temporal dimensions are important for jaw pain. Further research is needed to confirm these findings and assess relationships between dimensions of pain as experienced in other chronic pain disorders.

Use of sonographic elastography of the masseter muscles for optimizing massage pressure: a preliminary study

To examine the stiffness of the masseter muscle using sonographic elastography and to investigate its relationship with the most comfortable massage pressure in the healthy volunteers. In 16 healthy volunteers (10 men and 6 women), the Masseter Stiffness Index (MSI) was measured using EUB-7000 real-time tissue elastography. They underwent massages at three kinds of pressures using the Oral Rehabilitation Robot (WAO-1). A subjective evaluation regarding the comfort of each massage was recorded on the visual analogue scale. Elastography was also performed in two patients with temporomandibular joint dysfunction with the myofascial pain. The mean MSI of the right and left muscles in the healthy volunteers were 0.85 +/- 0.44 and 0.74 +/- 0.35 respectively. There was no significant difference between the right and left MSI in the healthy volunteers. The MSI was related to massage pressure at which the healthy men felt most comfortable. The two temporomandibular disorder patients had a large laterality in the MSI. The MSI was related to the most comfortable massage pressure in the healthy men. The MSI can be one index for determining the massage pressure.

Patient responses to vacuum formed splints compared to heat cured acrylic splints: pilot study

OBJECTIVE

Vacuum formed and heat cured acrylic splints have been used in the diagnosis and treatment of temporomandibular disorders. The aim of this study was to evaluate patient's preference to either the vacuum formed or the heat cured acrylic splint.

MATERIAL AND METHODS

Twenty patients planned to receive splints were chosen from the dental school. Both types of occlusal splints were fabricated for each of them. Each patient used the splints alternatively on a nightly basis for 3 weeks. After 3 weeks, each patient completed a questionnaire regarding the comfort, fit, retention, occlusal contact, taste, gingival and lip irritation, smoothness and smelling. Statistical analysis was conducted by the MacNemar's Chisquare test.

RESULTS

There was no statistical difference in patient's responses to the different splint materials except for the comfort of wearing through the night.

CONCLUSION

The vacuum formed and heat cured acrylic splint may be equally worn in patient preference for treatment of temporomandibular disorders.

Oral appliances in the management of temporomandibular disorders

Various types of oral appliances (OAs) have been used for over half a century to treat temporomandibular disorders (TMDs), but there has been considerable debate about how OAs should be designed, how they should be used, and what they actually do therapeutically. However, there is enough information in the scientific literature at this time to reach some evidence-based conclusions about these issues. The main focus of this review is on the materials and designs of various OAs in terms of their proposed mechanisms of action and their claimed clinical objectives. Based on current scientific evidence, an analysis is presented regarding the role that OAs can or cannot play in the management of TMDs. Finally, the concept that OAs may be an effective treatment modality for some TMDs owing to their potential for acting as an elaborate placebo rather than any specific therapeutic mechanism is considered.

Muscle disorders and dentition-related aspects in temporomandibular disorders: controversies in the most commonly used treatment modalities

This review explores the aetiology of temporomandibular disorders and discusses the controversies in variable treatment modalities.Pathologies of the temporomandibular joint (TMJ) and its' associated muscles of mastication are jointly termed temporomandibular disorders (TMDs).TMDs present with a variety of symptoms which include pain in the joint and its surrounding area, jaw clicking, limited jaw opening and headaches. It is mainly reported by middle aged females who tend to recognize the symptoms more readily than males and therefore more commonly seek professional help.Several aetiological factors have been acknowledged including local trauma, bruxism, malocclusion, stress and psychiatric illnesses. The Research Diagnostic Criteria of the Temporomandibular Disorders (RDC/TMD) is advanced to other criteria as it takes into consideration the socio-psychological status of the patient.Several treatment modalities have been recommended including homecare practices, splint therapy, occlusal adjustment, analgesics and the use of psychotropic medication; as well as surgery, supplementary therapy and cognitive behavioural therapy. Although splint therapy and occlusal adjustment have been extensively used, there is no evidence to suggest that they can be curative; a number of evidence-based trials have concluded that these appliances should not be suggested as part of the routine care.Surgery, except in very rare cases, is discouraged since it is the most invasive alternative; recent studies have shown healthier outcome with cognitive behavioural therapy.

Patient- and population-reported outcomes in public health dentistry: oral health-related quality of life

At present no process is in place in the United States to comprehensively monitor the national burden of oral diseases from the perspective of oral health-related quality of life (OHRQoL), yet available evidence shows that a substantial percentage of the adult population rates their oral health poorly. This article reviews applications of OHRQoL in dental public health. The authors specifically review its use, contributions, and needed advances in: (1) monitoring the impacts of oral diseases on OHRQoL at the national level, and in public health surveillance at the state and local levels; (2) treatment outcomes research and program evaluation; and (3) clinical practice.

Influence of psychological factors on risk of temporomandibular disorders

Psychological characteristics potentially may be a cause or consequence of temporomandibular disorder (TMD). We hypothesized that psychological characteristics associated with pain sensitivity would influence risk of first-onset TMD, but the effect could be attributed to variation in the gene encoding catechol-O-methyltransferase (COMT). We undertook a prospective cohort study of healthy female volunteers aged 18-34 yrs. At baseline, participants were genotyped, they completed psychological questionnaires, and underwent quantitative sensory testing to determine pain sensitivity. We followed 171 participants for up to three years, and 8.8% of them were diagnosed with first-onset TMD. Depression, perceived stress, and mood were associated with pain sensitivity and were predictive of 2- to 3-fold increases in risk of TMD (P < 0.05). However, the magnitude of increased TMD risk due to psychological factors remained unchanged after adjustment for the COMT haplotype. Psychological factors linked to pain sensitivity influenced TMD risk independently of the effects of the COMT haplotype on TMD risk.

Association between anterior tooth wear and temporomandibular disorder pain in a German population

STATEMENT OF PROBLEM

Bruxism is purported to be a risk factor for temporomandibular disorder (TMD) pain, but the association requires clarification.

PURPOSE

The purpose of this study was to investigate the relation between anterior tooth wear as an indicator for bruxism and the presence of TMD pain.

MATERIAL AND METHODS

Study subjects included 646 participants (age range 35 to 44 years) of a national oral health survey in Germany. Anterior tooth wear was registered for each anterior tooth with a 4-point scale (none, mild, moderate, and severe wear). Temporomandibular disorder was defined as self-reported pain in the face, jaw muscles, and/or temporomandibular joint (TMJ) during the last month, according to either the German version of the Research Diagnostic Criteria for Temporomandibular Disorders or the response to a question about pain in the masticatory muscles or the TMJ according to the Helkimo-Index. A multiple logistic regression analysis, controlling for the effects of age and gender, investigated the linear relationship between increased tooth wear and the risk of TMD pain.

RESULTS

After adjusting for age and gender, an odds ratio of 1.11 (95% confidence interval: 0.7-1.8) indicated that the risk of TMD pain increased an estimated 11% per unit increase of tooth wear. There was no statistically significant or clinically relevant relationship between a linear increase of tooth wear and risk of TMD pain.

CONCLUSION

Anterior tooth wear was not associated with self-reported TMD pain in 35- to 44-year-old subjects. Using anterior tooth wear as an indicator for long-term bruxing behavior, a clinically relevant dose-response relationship between this type of bruxism and TMD pain does not appear to exist.

Regional myofascial pain: diagnosis and management

This chapter defines and describes the condition that is known by the term myofascial trigger point pain syndrome. An outline is given of the current state of knowledge of the pathophysiology of myofascial trigger points, including the latest details from needle microdialysis in near real-time. The clinical features of this pain syndrome are summarised in general terms and the reliability of the clinical diagnosis is discussed. The clinical evidence for and against the common therapeutic interventions used in the management of myofascial pain is reviewed in detail and some tentative conclusions are reached with respect to needling therapies.

Comparison of habit reversal and a behaviorally-modified dental treatment for temporomandibular disorders: a pilot investigation

This study tested the hypothesis that a habit reversal program emphasizing awareness and reduction of masticatory muscle activity would significantly reduce pain in patients diagnosed with chronic temporomandibular disorder (TMD) and would be a competitive alternative to a behaviorally-modified dental intervention. Eight individuals diagnosed with TMD were randomly assigned to a splint therapy or habit reversal group. Patients in the splint group received an interocclusal appliance (splint) fabricated from acrylic and were instructed to wear the splint day and night up to a maximum of 20 h per day. Patients in the habit reversal group were given a pager and instructed to check tooth position and masticatory muscle tension when paged. Paging occurred approximately once every 2 h during the day, but not at night. Both groups were instructed to avoid tooth contact and relax the masticatory muscles during the 4 weeks of active treatment. Outcome data were collected at 1 month and 1 year post-treatment intervals. Pain decreased significantly for both groups and did not differ between groups. Habit reversal may be as effective as a behaviorally-modified splint therapy for TMD-related pain.

Occlusal Risk Factors for Temporomandibular Disorders

OBJECTIVE

To determine the role of occlusal variables (overbite; overjet; number of anterior and posterior teeth; bilateral canine guidance on lateral and protrusive movements; anterior centric slide; Angle Classes I, II, and III malocclusion) as risk indicators for the development of temporomandibular disorders (TMDs).

MATERIALS AND METHODS

Seventy-two TMD patients with myofascial pain, with or without limited opening and arthralgia, as well as 30 age- and gender-matched pain-free concurrent controls were included. The association (critical odds ratio [OR] = 2.0) between the significant occlusal variables and TMD was calculated. Confounders were controlled in the inclusion-exclusion criteria as well as in the analysis stage (unconditional logistic regression) by variation in the OR (15%).

RESULTS

Angle Class II malocclusion (crude OR = 8.0, confidence interval [CI] = 2.2 to 29.3) and the absence of bilateral canine guidance on lateral excursion (crude OR = 3.9, CI = 1.6 to 9.7) were statistically more common in patients than in controls. Spontaneous pain as well as pain on palpation (Class II or higher) were also statistically worse in TMD patients. Significant confounders (ie, employment, age, cigarette and alcohol consumption) acted as effect modifiers not changing the critical OR (adjusted OR Angle Class II and bilateral canine guidance = 8.3 to 12.4 and 2.2 to 4.1, respectively).

CONCLUSIONS

Absence of bilateral canine guidance on lateral excursion and particularly Angle Class II malocclusion were considered important risk indicators for the development of TMD in this investigation, even when some sociodemographic factors were considered as effect modifiers.

Temporomandibular disorders and other causes of facial pain

Temporomandibular disorders and facial pain cause significant discomfort and disability for affected patients. Understanding the clinical presentation, pathogenesis, and therapy is essential in helping patients who have these problems. This article critically reviews these aspects, with an emphasis on their relationship to headache.

Therapie bei Schmerzen der Kaumuskulatur

Myalgias of the masticatory muscles are the most frequent noninfectious complaints in the orofacial region. After summarizing the current knowledge on the physiology, etiology, pathophysiology, diagnosis, and differential diagnosis of masticatory muscle pain, we specifically focus on management recommendations. Results of an extensive literature search show that for the majority of patients pain reduction or pain relief can be achieved with noninvasive reversible methods. Longitudinal short- and long-term studies have revealed that different therapeutic measures are similarly effective. In patients with chronic masticatory myalgias associated with psychosocial impairment, however, additional involvement of a psychotherapist is crucial.

The efficacy of acupuncture in the treatment of temporomandibular joint myofascial pain: A randomised controlled trial

OBJECTIVES

To compare the effect of real acupuncture and sham acupuncture in the treatment of temporomandibulat joint myofascial pain, in order to establish the true efficacy of acupuncture.

METHODS

A double blind randomised controlled trial conducted in the TMD Clinic, at the School of Dentistry, The University of Manchester. Twenty-seven patients were assigned to one of two treatment groups. Group 1 received real acupuncture treatment whilst Group 2 received a sham acupuncture intervention. Both the assessor and the patient were blinded regarding the group allocation. Baseline assessment of the outcome variables was made prior to the first treatment session, and was repeated following the last treatment.

RESULTS

The results demonstrated that real acupuncture had a greater influence on clinical outcome measure of TMJ MP than those of sham acupuncture, and the majority of these reached a level of statistical significance.

CONCLUSION

Acupuncture had a positive influence on the signs and symptoms of TMJ MP. In addition, this study provides evidence that the Park Sham Device was a credible acupuncture control method for trials involving facial acupoints.

Temporomandibular disorders and headache

Headache is a common symptom, but when severe, it may be extremely disabling. It is assumed that patients who present to dentists with headache often are diagnosed with a temporomandibular disorder (TMD), although many may have migraine. TMD as a collective term may include several clinical entities, including myogenous and arthrogenous components. Because headache and TMD are so common they may be integrated or separate entities. Nevertheless, the temporomandibular joint (TMJ) and associated orofacial structures should be considered as triggering or perpetuating factors for migraine. This article discusses the relationship between the TMJ, muscles, or other orofacial structures and headache.

Pivot appliances ? is there a distractive effect on the temporomandibular joint?

The purpose of this study was to investigate the distractive effect of posterior occlusal pivots on the temporomandibular joint. The study comprised 23 healthy subjects. None of them had a third molar and none of them had a missing tooth or showed tooth mobility. All subjects clenched (i) on 1 mm tin foil positioned between the teeth 17/47 and 27/37; (ii) on a stiff bite registration material of 1 mm thickness that prevented protrusion because of its bold occlusal relief. During clenching on the tin foil and on the protrusion preventing bite registration material, respectively, the vertical and horizontal condylar position was measured using a 6 d.f. ultrasonic motion analyser. Clenching with maximal force on the tin foil lead to a noticeable anterior downward directed movement of the condyle. Clenching on the protrusion preventing pivot, however, caused a statistically significant upward condylar movement of about 0.3 mm. These results indicate that occlusal pivots have no distractive effect on the temporomandibular joint but can lead to unwanted joint compression, if they are designed in a way that is preventing protrusion.

Positive and negative affect and oral health-related quality of life

Background

The aims of the study were to assess the impact of both positive (PA) and negative affect (NA) on self-reported oral health-related quality of life and to determine the effect of including affectivity on the relationship between oral health-related quality of life and a set of explanatory variables consisting of oral health status, socio-economic status and dental visiting pattern.

Methods

A random sample of 45–54 year-olds from metropolitan Adelaide, South Australia was surveyed by mailed self-complete questionnaire during 2004–05 with up to four follow-up mailings of the questionnaire to non-respondents (n = 986 responded, response rate = 44.4%). Oral health-related quality of life was measured using OHIP-14 and affectivity using the Bradburn scale. Using OHIP-14 and subscales as the dependent variables, regression models were constructed first using oral health status, socio-economic characteristics and dental visit pattern and then adding PA and NA as independent variables, with nested models tested for change in R-squared values.

Results

PA and NA exhibited a negative correlation of -0.49 (P < 0.01). NA accounted for a larger percentage of variance in OHIP-14 scores (3.0% to 7.3%) than PA (1.4% to 4.6%). In models that included both PA and NA, PA accounted for 0.2% to 1.1% of variance in OHIP-14 scores compared to 1.8% to 3.9% for NA.

Conclusion

PA and NA both accounted for additional variance in quality of life scores, but did not substantially diminish the effect of established explanatory variables such as oral health status, socio-economic status and dental visit patterns.

A method for studying jaw muscle activity during standardized jaw movements under experimental jaw muscle pain

This paper describes a method for studying superficial and deep jaw muscle activity during standardized jaw movements under experimental jaw muscle pain. In 22 healthy adults, pain was elicited in the right masseter muscle via tonic infusion of 4.5% hypertonic saline and which resulted in scores of 30-60 mm on a 100-mm visual analogue scale. Subjects performed tasks in five sessions in a repeated measures design, i.e., control 1, test 1 (during hypertonic or isotonic saline infusion), control 2 (without infusion), test 2 (during isotonic or hypertonic saline infusion), control 3 (without infusion). During each session, subjects performed maximal clenching and standardized jaw tasks, i.e., protrusion, lateral excursion, open/close, chewing. Mandibular movement was recorded with a 6-degree-of-freedom tracking system simultaneously with electromyographic (EMG) activity from the inferior head of the lateral pterygoid muscle with fine-wire electrodes (verified by computer tomography), and from posterior temporalis, the submandibular muscle group and bilateral masseter muscles with surface electrodes. EMG root mean square values were calculated at each 0.5 mm increment of mandibular incisor movement for all tasks under each experimental session. This establishes an experimental model for testing the effects of pain on jaw muscle activity where the jaw motor system is required to perform goal-directed tasks, and therefore should extend our understanding of the effects of pain on the jaw motor system.

The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder

BACKGROUND

Treatment recommendations for patients with painful temporomandibular disorders (TMDs) range from conservative treatments such as physiotherapy to aggressive and irreversible treatments such as restorative reconstruction and joint surgery.

METHODS

The authors randomized 200 subjects diagnosed with TMD into three groups: usual conservative, dentist-prescribed self-care treatment without any intraoral splint appliance (UT); UT plus a conventional flat-plane hard acrylic splint (HS); and UT plus a soft vinyl (a low-cost athletic mouth guard) splint (SS). Subjects completed questionnaires and clinical examinations at three, six and 12 months.

RESULTS

The authors observed no significant differences among the groups in TMD-related pain levels or other common signs and symptoms of TMD at baseline (BL) or at any follow-up. The changes from BL were comparable for all three groups. The authors did not note any significant differences at any follow-up for compliance with study protocols or for occurrences of adverse effects from either splint type. For HS versus SS, there were significant differences in rates of splint use, but these differences were not accompanied by differences in either self-reported symptoms or in clinical findings.

CONCLUSIONS

All patients improved over time, and traditional splint therapy offered no benefit over the SS splint therapy. Neither splint therapy provided a greater benefit than did self-care treatment without splint therapy.

CLINICAL IMPLICATIONS

These findings suggest that clinicians who treat patients with TMD should consider prescribing low-cost nonsplint self-care therapy for most patients.

The treatment of temporomandibular disorders with stabilizing splints in general dental practice

BACKGROUND

The authors evaluated temporomandibular disorder (TMD) outcomes in general dental practice one year after treatment with stabilizing splints (SS) or nonoccluding control splints (CS).

METHODS

Seventy-two randomly allocated subjects completed initial treatment. The outcomes measures were a pain visual analog scale (VAS), muscle tenderness, temporomandibular joint (TMJ) tenderness, interincisal opening, TMJ clicks and headaches. After initial treatment, 81 percent of the subjects were found to have been treated satisfactorily. The dentists referred the remaining subjects to a dental hospital. At one year, the authors recalled 52 of the original subjects for evaluation.

RESULTS

Improvements after initial treatment were maintained at one year for all outcomes, except for TMJ clicking, which returned to pretreatment levels. Eighty-one percent of the subjects rated their treatment as either good or excellent in reducing jaw pain. The authors found that subjects were aware of more of their TMJ clicks than dentists observed at the one-year clinical examination, but most subjects thought their clicking or the associated pain had been reduced. Fifty-five percent subjects had used their splints in the previous six months, but only 31 percent of these had done so daily. There were no significant differences between splint groups.

CONCLUSION

At one year, a good response to TMD treatment in general practice had been maintained, but many subjects still had clicking TMJs.

CLINICAL IMPLICATIONS

Trained dentists can manage TMD satisfactorily, with only a small proportion of patients needing specialist attention.

Anterior midline point stop device (AMPS) in the treatment of myogenous TMDs: Comparison with the stabilization splint and control group

Two occlusal splints, the full-arch stabilization splint and the anterior midline point stop (AMPS) device, were evaluated for their efficiency in relieving myogenous temporomandibular disorders (TMD). One hundred and fourteen patients with myogenous TMD were distributed into 3 groups. The first group was treated with the AMPS device, the second with the stabilization splint, and the third group was the control group. Pain intensity was scored using the visual analogue scale before treatment and 1 month and 3 months after treatment. Statistical Package for the Social Sciences (SPSS, Chicago, Ill) and multiple comparisons tests were used to compare results before and after treatment and to compare the groups. The use of AMPS device in the first group resulted in a significant improvement after 1 month and 3 months (P < or = .001) and showed a 56.66% pain reduction. A significant improvement was also noticed in the second group (P = .001) with a 47.71% pain reduction. Although pain reduction percentage appeared more in the first group, this was not statistically significant. There was a highly significant difference between groups treated with both kinds of splints and the control group. It was concluded that both types of occlusal splints are beneficial to patients with myogenous TMD.

Clinical comparison between two different splint designs for temporomandibular disorder therapy

OBJECTIVE

To compare splint therapy in temporomandibular disorder (TMD) patients using two splint designs.

MATERIAL AND METHODS

In a double-blind randomized parallel trial, 40 consenting patients were selected from the dental faculty pool of TMD patients. Two splint designs were produced: an ordinary stabilization (Michigan type) and a NTI (Nociceptiv trigeminal inhibition). The differences in splint design were not described to the patients. All patients were treated by one operator. A separate, blinded, examiner assessed joint and muscle tenderness by palpation and jaw opening prior to splint therapy, and after 2 and 6 weeks' and 3 months' splint use during night-time. The patients reported headache and TMD-related pain on a visual analog scale before and after splint use, and were asked to describe the comfort of the splint and invited to comment.

RESULTS

Thirty-eight patients with mainly myogenic problems were observed over 3 months. A reduction of muscle tenderness upon palpation and self-reported TMD-related pain and headache and an improved jaw opening was seen in both splint groups (p < 0.05; paired t-test and Wilcoxon signed-ranks tests). There were no changes for TM joint tenderness upon palpation. No differences were noted between the two splint designs after 3 months for the chosen criteria of treatment efficacy (p > 0.05; Mann-Whitney U-test).

CONCLUSION

No differences in treatment efficacy were noted between the Michigan and the NTI splint types when compared over 3 months.

Patterns of Pain Variation Related to Myogenous Temporomandibular Disorders

OBJECTIVES

Myogenous temporomandibular disorders are characterized by jaw muscle pain. The aims were: 1) to characterize this pain generally in terms of intensity, frequency, duration, and behavior across a period of 2 weeks; 2) to identify main intraday pain patterns and to examine whether subgroups of patients in this respect differed in clinical, demographic, pain and sleep variables, psychosocial factors, and use of medication; and 3) to investigate some possible interday trends of pain intensity at a group level.

METHOD

One hundred thirty-three patients with myogenous temporomandibular disorders completed a 2-week diary, rating pain intensity (100 mm Visual Analog Scale [VAS]), duration, behavior (verbal 6-point scale), and medication use on 4 times of the day. Furthermore, questionnaires were completed to score pain period before seeking treatment, spread of pain, and demographic, psychosocial, and sleep variables.

RESULTS

In the diary, pain intensity, frequency, daily pain duration, and the score of pain behavior were on average 29.1 mm, 69% of the scoring times, 5.5 hours, and 1.8 points (approaching "pain present, but I can ignore it at times"), respectively. Pain intensity was, on average, maximal late in the day (before dinner or bedtime) for the majority of patients (79%) and early in the day (before breakfast or lunchtime) for the minority (21%). The larger subgroup had a significantly higher daily pain intensity, more frequently a widespread pain and problems with falling asleep at bedtime, agreed more about the role of a physician as an external health locus of control, and had a more distancing coping style. Both subgroups were similar for other variables, most notably in the level of state anxiety and depressive mood, and in a sparse use (7.8% of all possible times) of over-the-counter medication. Daily mean VAS scores, averaged across patients, were approximately constant for the various diary days. Both the daily mean and maximal VAS score were not related to a specific day of the week.

CONCLUSIONS

Two main daily pain patterns occur in patients with myogenous temporomandibular disorders (79%: maximal pain late in the day; 21%: early in the day), which might be related to differences in processes that influence pain sensitivity and patterns of jaw muscle activation. The interday similarities in pain level suggest that a sustained influence of counseling after the intake or an influence of a common behavioral pattern with a cycle duration of a week are not involved.

Self-reported remission, difficulty, and satisfaction with nonsurgical therapy used to treat anterior disc displacement without reduction

OBJECTIVE

The purpose of this study was to identify the appropriate treatment element for initial anterior disc displacement without reduction subjects.

STUDY DESIGN

Sixty-nine consecutive patients with temporomandibular joint disc displacement without reduction confirmed on magnetic resonance images were randomly divided into 3 experimental treatment groups. The treatment of group 1 consisted of short-term nonsteroidal anti-inflammatory drugs and self-care instructions (palliative care group); group 2, nonsteroidal anti-inflammatory drugs, self-care instructions, and occlusal appliance and mobilization therapy (physical medicine group); and group 3, no treatment (control group). Outcomes were assessed by means of a 5-item questionnaire that evaluated (1) symptom improvement, (2) difficulty of treatment, and (3) satisfaction with treatment during the 8-week observation period.

RESULTS

Improvement scores in the palliative care group were significantly better than those in the physical medicine group or the no-treatment group. Satisfaction scores showed no significant difference among the 3 groups. Difficulty from treatment for the physical medicine group was significantly greater than that for other 2 groups.

CONCLUSION

These data suggest that palliative care would be more appropriate as the initial therapy to treat painful anterior disc displacement without reduction.

Treatment of temporomandibular disorders by stabilising splints in general dental practice: results after initial treatment

INTRODUCTION

Little is known about how effective general dental practitioners (GDPs) are in treating temporomandibular disorders (TMD). The overall aim of this study was to compare the lower stabilising splint (SS) with a non-occluding control (CS) for the management of TMD in general dental practice.

METHOD

A total of 93 TMD patients attending 11 GDPs were randomly allocated to SS or CS. Diagnosis was according to International Headache Society Criteria. Outcome criteria included pain visual analogue scale (VAS), number of tender muscles, aggregate joint tenderness, inter-incisal opening, TMJ clicks and headaches. Splints were fitted one week after baseline and patients were followed-up every three weeks to three months; those not responding to CS after six weeks (< 50% VAS reduction) were crossed over to SS for a further three months.

RESULTS

Documentation was returned from nine GDPs for 72 patients (38 for SS, 34 for CS). At six weeks, mean improvements were noted for all outcome criteria, but less so for clicking. There were no significant differences between splints [chi(2)]. Seventeen CS patients had < 50% VAS reduction and were provided with SS in the cross-over group. CS patients with >50% VAS reduction were significantly younger than CS patients who crossed-over (ANOVA, p=0.009) and had significantly less diagnoses of TMJ clicking (chi(2), p<0.05). At the conclusion of the trial 16 patients were referred for specialist management: 11 non-responders (< 50% VAS reduction), one of whom needed occlusal adjustment and five responders also needing occlusal adjustment.

CONCLUSIONS

At six weeks SS gave similar relief to CS for all outcome criteria. Patients who crossed-over from CS to SS were more likely to be older and have clicking TMJs. At the end of treatment nine of 11 non-responders to SS had a diagnosis of disc displacement with reduction. However, 80% TMD patients were managed effectively by GDPs using splints for periods of up to five months.

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

Stabilisation splint therapy for temporomandibular pain dysfunction syndrome

BACKGROUND

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.

OBJECTIVES

To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome.

SEARCH STRATEGY

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.

SELECTION CRITERIA

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 COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

REVIEWER'S CONCLUSIONS

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.

Vertical jaw separation and masseter muscle electromyographic activity: a comparative study between asymptomatic controls & patients with temporomandibular pain & dysfunction

The aims of the present study were to assess the relationship pattern between bilateral masseter muscle electromyographic (MEMG) activity recordings and vertical jaw separation (VJS). Asymptomatic subjects (n = 15) were compared with age and gender-matched patients (n = 18) with temporomandibular pain and dysfunction (TMPD); before and after undergoing interocclusal appliance (IOA) therapy for 4 months. In asymptomatic subjects a bilateral minimum MEMG activity was found in a 'resting zone' at approximately a quarter of maximum mandibular opening (mean, 15.4 mm of VJS; range, 5.5-22.5 mm including overbite). No overall relationship between MEMG and VJS was shown for patients with TMPD. After successful IOA therapy, the majority of TMPD patients (14 of 18) showed normalization of the relationship between MEMG and VJS, but electromyographic assessment was not found to be of value as a single objective assessment parameter in evaluating the resolution of TMPD or the effectiveness of IOA therapy.

[Differential and common characteristics of patients with atypical facial pain and craniomandibular dysfunction]

BACKGROUND

Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP.

METHOD

A total of 124 consecutive patients with CMD ( n=108) or AFP ( n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist.

RESULTS

The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor ( p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status.

CONCLUSIONS

CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.

Orthosis thickness and its effect on temporomandibular joint space

The object of this study was to determine the effect of varying thicknesses of orthoses on temporomandibular (TM) joint space. The TM joint space was measured using the centric cut view of tomographic images. The measurements used selected fixed landmarks of the joint complex anatomy to find joint space. The fixed points used for the measurement of the joint space are no different than the fixed points methodology used in orthodontic cephalometric measurements. The placement of the fixed points on a radiograph is subjective. Degrees of accuracy can be accomplished with consistent use just as in the practice of cephalometric measurements. Results of such measurements do provide a relatively true record of the actual condyle and fossa relationship. The study concluded that the thickness of the orthosis moved the condyle downward and horizontally without regard to its original positioning. If clinicians know the condylar position before and after orthosis placement, a concentric position of the condyle can be established to assist in the patient's second phase treatment. Further research will prove that the physiological and anatomical balance of the temporomandibular joint complex is important in effectively managing craniofacial pain patients.

Effects of interocclusal appliances on EMG activity during parafunctional tooth contact

To test the hypothesis that a flat plane interocclusal appliance affects the electromyographic (EMG) activity of the temporalis and masseter muscles in pain-free individuals, maxillary splints were fabricated for 20 individuals who reported no history, signs or symptoms of myofascial pain or arthralgia as determined by two trained, independent examiners. Subjects were instructed to establish light tooth contact, maximum clenching, and moderate clenching with/without the splint in place (as determined by random assignment) while EMG data from the left and right temporalis and masseter muscles were recorded. A 5-min biofeedback training session to relax the masticatory muscles was followed by a repetition of the tooth contact/clenching tasks with/without the splint in place. With the splint in place, the activity of the temporalis muscles decreased for all tasks, significantly for the left and right temporalis under maximal clenching and for the right temporalis under moderate clenching. In contrast, the activity of the masseter muscles increased under light and moderate clenching (significantly for the left masseter under moderate clenching) and decreased slightly under maximal clenching. The effectiveness of interocclusal appliances may be due to mechanisms other than redistribution of adverse loading.

[Do questionnaires for patients improve the diagnosis of craniomandibular dysfunction with chronic facial pain? A patients' questionnaire study from outpatient practice]

PURPOSE

The differential diagnosis of craniomandibular dysfunction (CMD) is of central importance for the therapy and diagnosis of chronic facial pain. Nevertheless, opinions on causes and treatment differ extremely and are sometimes even contradictory. The necessity of obtaining a precise and thorough patient history is indisputable. This raises the question of whether a questionnaire can offer additional information in order to improve the quality of the history, diagnosis and therapy.

MATERIAL AND METHODS

From May 1998 until February 1999, 230 patients who received a monoblock were requested to fill out a questionnaire referring to the previous 4-6 weeks, as an addition to the initial diagnostic tests. In 175 cases we were able to repeatedly examine the patient and compare the effects of therapy with the questionnaires. The questionnaire contains 14 visual, 11-step analogue scales, which are to be marked spontaneously and subjectively. The test-retest reliance at 1 week before treatment was r=0.82 ( n=86). The questionnaire requests information on diverse kinds of pain, sensations and findings in the dental, oral, maxillary and facial areas. For evaluation, a summation-score is built.

RESULTS

To our surprise, from a total of 175 patients 41.7% ( n=73) indicated their pain exclusively on the questionnaire. The number and frequency of answers indicated CMD. The average score of the patients whose pain was only mentioned on the questionnaire (31.16+/-19.16) was just slightly below the score of patients with additional, verbal pain descriptions (36.49+/-20.79).

CONCLUSION

The picture provided by the answers is impressive for the patient, improves compliance and makes diagnosis easier. In the same way, one can document the success of therapy and explore individual outcomes which show a resistance to therapy.

First night effect of an interocclusal appliance on nocturnal masticatory muscle activity

The purpose of this study was to examine the effect of an interocclusal appliance on nocturnal masticatory muscle activities. Six healthy Japanese males (mean age: 26.8 years) participated in this study. Electromyographic (EMG) activities of the right anterior temporalis and masseter muscles were recorded using a portable EMG recording unit at night both with and without an interocclusal appliance. In both muscles, the maximal EMG activity and the number of bruxing events decreased significantly by wearing the appliance. Moreover, the duration of a higher level of muscle activity was decreased while that of a lower level of muscle activity increased by wearing the appliance in both muscles. These findings suggest that nocturnal masticatory muscle activity is significantly reduced by wearing an interocclusal appliance, and that the use of such an appliance at night could help to relax masticatory muscles.

Efficiency of occlusal appliance therapy in secondary otalgia and temporomandibular disorders

In clinical practice, it is commonly assumed that occlusal splints have therapeutic value in the treatment of temporomandibular disorders CTMD), but the evidence based on randomized controlled trials is scarce. This study evaluated the short-term (10-week) efficacy of a stabilization splint in subjects with recurrent secondary otalgia and active TMD treatment need using a randomized, controlled, double-blind design. Thirty-six subjects were randomly allocated to the two treatment groups: the stabilization splint and the control splint group. After 10 weeks' treatment, the intensity of secondary otalgia, measured on a VAS scale (from 0 to 100 mm), decreased statistically significantly in the stabilization splint group (t 2.12; P 0.006), but not in the control group. Improvement in active TMD treatment need in subjects showing moderate or severe signs and symptoms of TMD was reported significantly more often in the stabilization splint group than in the control splint group (chi2 5.71; P.017). A statistically significant decrease in the Helkimo clinical dysfunction index was seen in the subjects with stabilization splint (Z-2.63; P.009), but not in the subjects with control splint. The results indicate that the use of a stabilization splint is beneficial with regard to secondary otalgia and active TMD treatment need.

TMD prevalence in rural and urban Native American populations

The purpose of this study was to assess the prevalence of TMD in a consecutive sample of 102 subjects from the Native American population living in an urban setting and 90 subjects living in a rural setting. The study utilized a clinical examination and standardized questionnaires. The sample age ranged from five to 84 years of age. The subjects were asked to estimate pain frequency, severity and daily pattern of jaw pain, difficulty in opening, joint clicking, and sleeping problems. Examination was performed on joint, masticatory, and cervical muscles, as well as occlusion. Data was collected and statistically analyzed. Statistically significant differences were found; however, the only statistically significant difference that might have clinical significance was more facial pain in the urban population.

Hypnorelaxation as treatment for myofascial pain disorder: a comparative study

BACKGROUND

Hypnorelaxation has a potentially beneficial effect in the treatment of masticatory myofascial pain disorders (MPD). However, there are no data regarding the efficacy of hypnorelaxation in the treatment of MPD compared with other accepted modes of treatment (such as occlusal appliance) or with the mere effect of time.

OBJECTIVE AND SUBJECTS

The purpose of the present study was to evaluate the effectiveness of hypnorelaxation in the treatment of MPD compared with the use of occlusal appliance and/or to minimal treatment. The study population consisted of 40 female patients with myofascial pain who were allocated to 1 of 3 possible treatment groups: (1) hypnorelaxation (n = 15), (2) occlusal appliance (n = 15), and (3) minimal treatment group (n = 10).

RESULTS

Both active treatment modes (hypnorelaxation and occlusal appliance) were more effective than minimal treatment regarding alleviating muscular sensitivity to palpation. However, only hypnorelaxation (but not occlusal appliance) was significantly more effective than minimal treatment with regard to the patient's subjective report of pain on the Visual Analog Scale.

CONCLUSION

Hypnorelaxation is an effective mode of treatment in MPD, especially with regard to some of the subjective pain parameters.

The role of minimal intervention in orthodontics

Less than 15% of the population develops a normal occlusion as defined by Angle in the permanent dentition. The term 'ideal' may therefore be a more appropriate description, and deviations from this esthetic and functional optimum should not be considered abnormalities in the true sense of the word. Current research indicates that few malocclusions compromise dental, periodontal or temporomandibular health. To determine whether or not protruded, irregular or maloccluded teeth merit orthodontic intervention is therefore a major challenge. Another challenge is to determine to what extent a limited treatment strategy may be successful in correcting the occlusal problems according to the perceived needs of the patients. I discuss these issues in my present communication and conclude that the major reasons for recommending orthodontic treatment are psychosocial in nature. I also conclude that the majority of the orthodontic cases require comprehensive treatment to achieve successful results. Orthodontic patients are typically satisfied with the outcome of the orthodontic intervention, reporting that the esthetic improvements and the increased functional comfort of the dentition have made significant contributions to their quality of life. Technological advances have made orthodontic treatment simpler and safer over the years. Considering the potential for long-lasting results and the low risk of iatrogenic effects if the patients comply with appropriate oral hygiene measures during active appliance therapy, I conclude that treatment of minor occlusal deviations may also be justified in subjects expressing a clearly defined subjective need for treatment.