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

Randomized Clinical Trial of Electrostimulation Therapies as an Adjuvant for the Treatment of Temporomandibular Disorders

We carried out a comparison of the neuromuscular and clinical effects produced by electrostimulation therapies, as an adjuvant to the use of occlusal splints (removable muscle relaxation apparatus) in patients with temporomandibular disorders In this simple randomized clinical trial, 91 patients were randomly divided into three groups. Group A (GA) received transcutaneous electrostimulation therapy and an occlusal splint, Group B (GB) received percutaneous electrostimulation therapy and an occlusal splint, and Group C (GC) received an occlusal splint. The neuromuscular activity, as well as the signs and symptoms of each patient, were evaluated every week throughout the treatment (T0 = baseline; T1 = 7 days; T2 = 14 days; T3 = 21 days; T4 = 28 days; and T5 = 35 days). Pain was measured with a visual analog scale, and neuromuscular electrical activity was determined by the root mean square of the masseter muscles through the use of a UNAM-CINVESTAV 1.2 electromyograph. Comparisons were made using ANOVA for repeated measures (p-value = 0.05). The comparison between the groups determined that muscle fatigue (p-value = 0.001), joint pain (p-value = 0.009), and muscle pain (p-value = 0.003) decreased to a greater extent, and in the short term for the group treated with transcutaneous electrostimulation therapy as an adjuvant to the use of the occlusal splint. The comparison between the groups determined that muscle fatigue (p-value = 0.001), joint pain (p-value = 0.009), and muscle pain (p-value = 0.003) decreased to a greater extent and in a shorter term in the GA (calculation therapy, transcutaneous electrostimulation) and GB (occlusal splint). Transcutaneous electrostimulation is a feasible and faster alternative that was accepted by most of the patients for treating temporomandibular disorders.

Structured critical analysis correction of a systematic review

OBJECTIVE

: Systematic reviews (SRs) are an increasingly important format in the scientific literature. Commentaries on improvements to the SR format have focused on methodological quality, but a greater concern is a frequent lack of critical analysis. A structured critical analysis (SCA) was described as a solution to this deficiency.

METHODS

: Recommendations and conclusions of a recent SR were analyzed with a SCA to address common problems previously reported with the SR format.

RESULTS

: Errors in the component studies and their interpretation by the SR that led to erroneous recommendations were presented. The 5-part SCA provided comprehensive analysis that corrected the SR, which had accepted the component study conclusions verbatim.

CONCLUSION

: The SCA is a logical approach to provide critical thinking in SRs to ensure appropriate conclusions. This is especially important, as many SRs report contradictory evidence. Also, the reader can use the SCA format to better understand existing literature.

Wear resistance and flexural properties of low force SLA- and DLP-printed splint materials in different printing orientations: An in vitro study

OBJECTIVES

To investigate the influence of material and printing orientation on wear resistance and flexural properties of one low force SLA- and two DLP-printed splint materials and to compare these 3D-printed splints to a subtractively manufactured splint material.

METHODS

Two DLP-printed (V-Print splint, LuxaPrint Ortho Plus) and one low force SLA-printed (Dental LT Clear) material, where specimens were printed in three printing orientations (0°, 45°, 90°), were investigated. In addition, one milled splint material (Zirlux Splint Transparent) was examined. A total of 160 specimens were produced for both test series. The two-body wear test was performed in a chewing simulator (80'000 cycles at 50 N with 5-55 °C thermocycling). Steatite balls were used as antagonists. The wear pattern was analyzed with a 3D digital microscope in terms of maximum vertical intrusion depth (mm) and total volume loss (mm³). The flexural properties were investigated by three-point bending in accordance with ISO 20795-1: 2013 (denture base polymers). The flexural strength (MPa) and the flexural modulus (MPa) were measured. Two-way ANOVA was performed to investigate the effects of the two independent variables material and printing orientation for the three 3D-printed materials. The comparison of the printing orientations within one material was carried out with one-way ANOVA with post-hoc Tukey tests.

RESULTS

Two-way ANOVA revealed that wear and flexural properties are highly dependent on the 3D-printed material (p < 0.001). Across groups, a significant effect was observed for wear depth (p = 0.031) and wear volume (p = 0.044) with regard to printing orientation but this was not found for flexural strength (p = 0.080) and flexural modulus (p = 0.136). One-way ANOVA showed that both DLP-printed groups showed no significant differences within the printing orientations in terms of wear and flexural properties. Dental LT Clear showed that 90° oriented specimens had higher flexural strength than 0° oriented ones (p < 0.001) and 45° oriented specimens also showed higher values than 0° ones (p = 0.038). No significant differences were observed within the printing orientations for flexural modulus and wear behaviour within this group. T-tests showed that the milled splints exhibited statistically higher wear resistance and flexural properties compared to all three 3D-printed splint materials (p < 0.001) and that highly significant differences were found between the 3D-printed splint materials for both test series.

CONCLUSION

Within the limitations of this in vitro study, it can be stated that wear behaviour and flexural properties are highly dependent on the 3D-printed material itself. Currently, milled splints exhibit higher wear resistance and flexural properties compared to 3D-printed splint materials. The printing orientation has a minor influence on the properties investigated. Nevertheless, two-way ANOVA also showed a significant influence of printing orientation in the wear test across groups and one-way ANOVA detected significant effects for SLA material in terms of flexural strength, with printing in 90° showing the highest flexural strength. Therefore, anisotropy was found in SLA material, but it can be limited with the employed printing parameters. Both DLP-printed materials showed no significant difference within the printing orientation.

Transcutaneous auricular vagus nerve stimulation for the treatment of myoarthropatic symptoms in patients with craniomandibular dysfunction - a protocol for a randomized and controlled pilot trial

BACKGROUND

Temporomandibular disorders (TMD) are a collective term for pain and dysfunction of the masticatory muscles and the temporomandibular joints. The most common types of TMD are pain-related, which may impact the psychological behavior and quality of life. Currently, the most popular methods for the treatment of TMD patients are occlusal splint therapy, often in combination with physical- and/or pharmacotherapy. However, due to the complexity of etiology, the treatment of chronic TMD remains a challenge. Recently, CE-certified systems for non-invasive VNS (transcutaneous auricular vagus nerve stimulation, taVNS) have become available and show positive effects in the treatment of chronic pain conditions, like migraine or fibromyalgia, with which TMD shares similarities. Therefore, it is the main purpose of the study to evaluate the feasibility of daily taVNS against chronic TMD and to assess whether there is an improvement in pain severity, quality of life, and kinetic parameters.

METHODS

This study is designed as a single-blinded, double-arm randomized controlled trial (RCT) in a 1:1 allocation ratio. Twenty adult patients with chronical TMD symptoms will be enrolled and randomized to stimulation or sham group. In the stimulation group, taVNS is performed on the left tragus (25 Hz, pulse width 250 µs, 28 s on/32 s off, 4 h/day). The sham group will receive no stimulation via a non-functional identical-looking electrode. Validated questionnaire data and clinical parameters will be collected at the beginning of the study and after 4 and 8 weeks. The compliance of a daily taVNS of patients with chronical TMD will be evaluated via a smartphone app recording daily stimulation time and average intensity. Additionally, the treatment impact on pain severity and quality of life will be assessed with different questionnaires, and the effect on the mandibular mobility and muscle activity will be analyzed.

DISCUSSION

This is the first clinical trial to assess the feasibility of taVNS in patients with chronic TMD symptoms. If taVNS improves the symptoms of TMD, it will be a significant gain in quality of life for these chronic pain patients. The results of this pilot study will help to determine the feasibility of a large-scale RCT.

TRIAL REGISTRATION

This study has been registered in the DRKS database (DRKS00029724).

An Evidence-Based Treatment of Myofascial Pain and Myofascial Trigger Points in the Maxillofacial Area: A Narrative Review

Myofascial pain (MFP) is characterized by localized pain in the maxillofacial region attributed to the presence of hypersensitive spots known as trigger points (TrPs). This condition is particularly prevalent in the maxillofacial area, warranting a comprehensive examination of evidence-based management techniques. This review aims to equip healthcare professionals with a more profound insight into evidence-based MFP management techniques, facilitating improved patient care and treatment outcomes. In this review, we conducted a thorough literature search using Google Scholar, Scopus, Web of Science (WOS), and MEDLINE, with the keywords "Myofascial pain syndrome," "Pain," and "Orofacial pain." Articles were selected based on their relevance to the study's objective. Pharmacological interventions, such as analgesics and muscle relaxants, are frequently prescribed. Additionally, a range of non-pharmacological modalities, including transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, topical applications, dry needling, TrP injections, oral myofunctional therapy, and stretching exercises, have demonstrated efficacy in MFP management. The authors hope to give clinicians a more thorough understanding of the therapies for MFP by conducting a rigorous evidence-based evaluation of pharmacologic and non-pharmacological treatments. Our findings support the use of a combined approach that integrates both pharmacological and non-pharmacological strategies for the holistic management of TrPs.

A Comparative Study of Condylar Bone Pathology in Patients with and without Temporomandibular Joint Disorders Using Orthopantomography

This study aimed to compare condylar bony pathology in patients with and without temporomandibular joint disorder (TMD) using orthopantomography at Ajman University dental clinics between 2017 and 2021. Patient data from the Ajman University archives were collected after obtaining ethical approval. OPG (orthopantomogram) views were evaluated for potential TMJ pathology. Three independent observers underwent calibration and image analysis, with their agreement level calculated using Kappa statistics (score 0.781). Condylar changes were coded from 0 to 6. Statistical tests such as the Mann-Whitney Test, Kruskal-Wallis test, Spearman's correlation, and logistic regression analysis were used to analyze the data. The inter-examiner reliability for OPG was 0.903, and intra-examiner reliability was 0.908. The most common condylar bony changes observed in OPG views were flattening and osteophyte. Female participants had a higher prevalence of all bony changes. Temporomandibular Disorder (TMD) can manifest with symptomatic and detectable bony changes in OPG views. The prevalence of temporomandibular disorder appeared similar between genders, but differences were observed regarding the number of teeth lost, with unilateral tooth loss being more common. Interestingly, bruxism did not seem to significantly impact of temporomandibular disorder patients.

Recommendations on the Use of Oral Orthotic Occlusal Appliance Therapy for Temporomandibular Joint Disorders: Current Evidence and Clinical Practice

Background

'Temporomandibular joint disorders (TMDs)' denote an umbrella term that includes arthritic, musculoskeletal and neuromuscular conditions involving the temporomandibular joint, the masticatory muscles, and the associated tissues. Occlusal devices are one of the common treatment modalities utilized in the conservative management of TMDs. The indications for the available 'oral splints' or 'oral orthotic occlusal devices' remain ambiguous.

Methods

A joint international consortium was formulated involving the subject experts at TMJ Foundation, to resolve the current ambiguity regarding the use of oral orthotic occlusal appliance therapy for the temporomandibular joint disorders based on the current scientific and clinical evidence.

Results

The recommendations and the conclusion of the clinical experts of the joint international consort has been summarized for understanding the indications of the various available oral orthotic occlusal appliances and to aid in the future research on oral occlusal orthotics.

Conclusion

The use of the oral orthotic occlusal appliances should be based on the current available scientific evidence, rather than the archaic protocols.

Influence of Soft Stabilization Splint on Electromyographic Patterns in Masticatory and Neck Muscles in Healthy Women

This study investigates the influence of soft stabilization splints on electromyographic patterns in masticatory and neck muscles in healthy women. A total of 70 healthy women were qualified for the research. The resting and clenching electromyographic patterns of the temporalis (TA), masseter (MM), digastric (DA), and sternocleidomastoid (SCM) muscles were measured using the BioEMG III™ apparatus. The interaction between splint application and resting muscle activity affected the results in all examined muscles except the temporalis muscle. A large effect size was observed in masseter (2.19 µV vs. 5.18 µV; p = 0.00; ES = 1.00) and digastric (1.89 µV vs. 3.17 µV; p = 0.00; ES = 1.00) both-sided RMS activity. Significant differences between the two conditions were observed in all Functional Clenching Indices (FCI) for MM, SDM, and DA muscles. All FCI values for the MM and DA muscles were significantly lower with than without the splint. We observed an increase in all activity indices due to splint application, which suggests a masseter muscle advantage during measurement. The soft stabilization splint influenced resting and functional activity in the MM, SDM, and DA muscles. During tooth clenching, a soft stabilization splint changed the involvement proportions of the temporalis and masseter muscles, transferring the main activity to the masseter muscles. Using a soft stabilization splint did not affect the symmetry of the electromyographic activity of the masticatory and neck muscles.

Efficacy of Arthrocentesis and Stabilization Splints in Treatment of Temporomandibular Joint Disc Displacement Disorder Without Reduction: A Systematic Review and Meta-analysis

Background

Temporomandibular joint disc displacement disorders are a group of temporomandibular disorders beside from other inflammatory disorders and growth related disorders of joint. The purpose of this analysis was to evaluate the efficacy of arthrocentesis procedure in comparison with stabilization splints used for disc displacement disorders without reduction.

Materials and Methods

A systematic search was done in electronic databases (PubMed, Cochrane Central, Web of Science). In addition to this hand search of references and grey literatures was done. Qualities of randomized controlled clinical trials were assessed by Cochrane's tool for Systematic Reviews of Interventions and the Newcastle-Ottawa Scale was followed to assess the prospective and retrospective studies. Outcome variables pain (VAS) and maximum mouth opening were assessed by the software review manager 5.03.

Results

A total of five studies were included in the review. Three studies showed greater improvement of symptoms in patients of arthrocentesis group in terms of maximum mouth opening, pain (VAS) value. Two other studies found no significant advantage of arthrocentesis over the other treatment protocol. The meta-analysis resulted in statistically significant difference between outcome variables favouring arthrocentesis group (VAS 1-10) (Mean Difference: 3.10; 95% CI 1.74, 4.45; P ≤ .00001, Mean difference: 2.00; 95% CI 0.29, 3.71; P = 0.02).

Conclusion

Arthrocentesis showed effective result in terms of increase in mouth opening and reduction of pain level compared to stabilization splint and other non-invasive approaches in patients with disc displacement disorders without reduction. Overall, results supported the rationale of using arthrocentesis in patients with disc displacement disorders without reduction.

Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Accuracy of 3D-Printed Occlusal Devices of Different Volumes Using a Digital Light Processing Printer

(1) Background: This in-vitro study was designed to investigate the accuracy of CAD/CAM fabricated occlusal devices with different heights and volumes. (2) Methods: Based on an intraoral scan, an occlusal device with a vertical bite elevation of 2.5 mm and 4.5 mm was digitally designed and 3D printed 10 times. The fabricated occlusal devices were digitized by an industrial structured light scanner (ILS) and provided in stl-format as test objects. The test objects were superimposed with the design dataset as reference to evaluate the accuracy of complete surfaces ([2.5_TOTAL] and [4.5_TOTAL]) with respect to their internal surfaces ([2.5_INTERNAL] and [4.5_INTERNAL]). The mean trueness and precision were calculated based on absolute mean deviation. Absolute and relative volume differences between reference and test were computed. Statistical significances were analyzed performing the Wilcoxon test (α = 0.05). (3) Results: As absolute mean deviation trueness values were obtained: 59 ± 5 µm for [2.5_INTERNAL], 98 ± 9 µm for [4.5_INTERNAL], 68 ± 1 µm for [2.5_TOTAL] and 90 ± 10 µm for [4.5_TOTAL]. The precision applying absolute mean deviation was 14 ± 8 µm for [2.5_INTERNAL], 22 ± 11 µm for [4.5_INTERNAL], 19 ± 10 µm for [2.5_TOTAL] and 26 ± 13 µm for [4.5_TOTAL]. The mean trueness and precision values differed significantly. Volume differences of 2.11% for [4.5_TOTAL] and of 2.35% for [2.5_TOTAL] in comparison to their reference file were evaluated. (4) Conclusions: Printed occlusal devices with minor height and volume were more accurate. Both types of devices exhibited results that were comparable to the literature.

Bonding Interface and Repairability of 3D-Printed Intraoral Splints: Shear Bond Strength to Current Polymers, with and without Ageing

This in-vitro study investigates the bonding interfaces reached by the conditioning of a splint material additively manufactured by digital light processing (AM base) as well as the shear bond strength (SBS) of resins bonded to these surfaces (repair material). Therefore, the AM base was either stored in dry for 12 h or wet environment for 14 days to simulate ageing by intraoral wear. The dry and wet group was bonded after physical and/or chemical conditioning to cylinders made from polymethylmethacrylate or four novel polymers allowing splint modifications. Blasted and methylmethacrylate (MMA)-conditioned Polymethylmethacrylate (PMMA) bonded to PMMA acted as the gold standard. The surface profiles revealed highest differences of Ra towards the gold standard in AM base conditioned with other than MMA after sandblasting. The adhesively bonded repair materials of the wet AM base were further aged in wet environment for 14 days. The SBS of the gold standard (25.2 MPa and 25.6 MPa) was only reached by PMMA bonded to blasted and MMA-conditioned AM base after dry (22.7 MPa) and non-conditioned after wet storage (23 MPa). Four repair materials failed to reach the threshold of 5 MPa after dry storage and three after wet storage, respectively. Non-conditioned AM base revealed the highest risk for adhesive fractures when using other resins than PMMA.

Variations in athletic performance with occlusal splint in track and field athletes: a randomized clinical trial

BACKGROUND

Several studies have been proposed with the aim to demonstrate correlations between the dento-mandibular apparatus and the skeletal muscle system of the human body even in regions distant from the oral cavity. However, a definite conclusion cannot be drawn. The aim of this paper is to demonstrate a possible correlation between dental occlusion and sport performances in track and field athletes.

METHODS

16 track and field athletes were enrolled for the study and were randomly divided in three groups: Untreated control group, Placebo group (with a lower plaque without occlusal coverage) and Treated group (with occlusal splint). Changes in sprint and jump performance were assessed on a weekly basis for 5 consecutive weeks, during which athletes had to wear oral devices, except for the first week of baseline, for at least 3 trainings lasting 2 hours per week. All participants performed the countermovement jump (CMJ), the drop jump (DJ), the 10m and 30m sprint tests, always on the same day on the week.

RESULTS

No statistically significant difference resulted between Control group and Placebo group and between Control group and Treated group. However it was possible to observe a clinical improvement of measurements obtained, especially for CMJ, 10m and 30m sprint tests. No variation neither statistical neither clinical was observed in DJ test analysis.

CONCLUSIONS

Even if statistically it was not possible to demonstrate an improvement in sport performance, most of the athlete analyzed showed better results during training session with occlusal splint compared to athlete without occlusal splint, in countermovement jump, in 10m and 30m sprint tests.

Occlusal devices in France: An assessment of professional practice

STATEMENT OF PROBLEM

Whether recommendations for the use of occlusal devices are made uniformly in terms of indications, designs, and wearing time is unclear. Different recommendations may lead to different clinical outcomes.

PURPOSE

The purpose of this survey was to assess the professional practice of dental surgeons in France regarding the use of occlusal devices.

MATERIAL AND METHODS

A 26-question cross-sectional survey was sent to a panel of French dentists via the County Councils of the Dental Order. The questionnaire concerned the amount of occlusion-related treatment, the use of an anterior deprogramming device, stabilization splint, and anterior repositioning appliance, and the patient follow-up as well as the drawbacks of using an occlusal device as a therapeutic solution. The statistical tests used in the study were the chi-square test and the Yate correction for continuity.

RESULTS

A total of 771 responses were received. Invasive options were still reported as being used as a first-line treatment for temporomandibular disorder, although a statistical difference was found between experienced and recently graduated practitioners, with recent graduates preferring noninvasive options as first-line treatment. Also, the results showed that anterior deprogramming devices were not used or that their application, particularly the length of treatment, was unfamiliar to practitioners. The anterior repositioning appliance seems to be used, but only a few practitioners integrate it into their practice. In general, about one-third of dentists appear to have a good knowledge of occlusion-related treatments, in particular, the use of occlusal devices.

CONCLUSIONS

The results indicated that only 20% to 30% of practitioners have good knowledge of contemporary occlusion-related practice. There is a need for the standardization of practice and improved education for practitioners in the use of occlusal devices.

Polymers for conventional, subtractive, and additive manufacturing of occlusal devices differ in hardness and flexural properties but not in wear resistance

OBJECTIVES

To investigate the wear resistance of polymers for injection molding, subtractive and additive manufacturing of occlusal devices in comparison with enamel antagonist wear and material properties (i.e., hardness, flexural strength, and flexural modulus).

METHODS

Injection molding was compared with milling and the additive technologies stereolithography, low force stereolithography, and digital light processing. For each material, eight specimens were produced for wear measurements. Extracted human premolars served as indenters. All samples were subjected to two series of a 2-body wear test consisting of 200,000 circular loading cycles with an applied load of 1) 20 N and 2) 50 N in a thermocycling environment (5/55 °C, 30 s, 3860 cycles, H₂O). Wear resistance was characterized by means of maximum depth and volume of the resulting traces. In addition, enamel wear of the indenters and Vickers hardness, flexural strength, and flexural modulus of the polymers were determined. Wear was statistically analyzed with linear general models for repeated measures and material properties with one-way ANOVA with post-hoc Tukey-HSD tests.

RESULTS

Wear of the antagonists was not influenced by the material (P ≥ 0.343). Likewise, no differences in wear resistance were found between materials after cyclic loading with 20 N or 50 N (P ≥ 0.074). Material properties investigated revealed decreased values for the resins for the additive manufacturing with the exception of flexural strength of one material.

SIGNIFICANCE

Within the limitations of this in-vitro study, arylates for conventional, subtractive, and additive manufacturing of occlusal devices differ in material properties but not in wear resistance and antagonist wear.

Temporomandibular joint injections in dogs with temporomandibular joint pain: 11 cases (2015-2019)

OBJECTIVES

To describe and evaluate the clinical application of temporomandibular joint injections using betamethasone and ropivacaine in German Shepherd dogs suffering from non-odontogenic orofacial pain due to temporomandibular dysplasia and/or osteoarthritis.

MATERIALS AND METHODS

Outcomes in dogs presented with clinical signs of non-odontogenic orofacial pain associated to temporomandibular joint dysplasia and/or arthritis and treated with a temporomandibular joint injection were retrospectively-prospectively evaluated.

RESULTS

The overall clinical signs free period ranged between 25 to 1579 days, with an average of 461 days. The clinical signs free period for temporomandibular joint osteoarthritis scores 1, 2 and 3 were on average 659 days (180-1579 days), 134 days (42-355 days) and 723 days (25-1377 days), respectively. Similarly the temporomandibular dysplasia scores 1, 2 and 3 were on average 306 days (26-1579 days), 1377 days and 669 days (25-1429 days) respectively. Those dogs in which only one side was injected the clinical signs free period average was 639 days (25-1578 days), compared with dogs in which both temporomandibular joints were injected showing a clinical signs free period average of 378 days (42-1377 days).

CLINICAL SIGNIFICANCE

The temporomandibular joint injection technique proved to be feasible with a decent outcome in dogs suffering from non-odontogenic orofacial pain associated with temporomandibular joint osteoarthritis and/or dysplasia. Further randomised studies are required to confirm the effectiveness of this intervention.

Efficacy of occlusal splints in the treatment of temporomandibular disorders: a systematic review of randomized controlled trials

OBJECTIVE

This systematic review aimed to assess the efficacy of occlusal splints in the treatment of temporomandibular disorders (TMDs).

MATERIAL AND METHODS

This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Four databases (Medline via Pubmed, Web of Science, Embase and Scopus) were searched, the last search was conducted on April 2020. Randomised controlled trials (RCTs) employing the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) or Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) as diagnostic criteria and including occlusal splint as one of the experimental groups were included in the present study. The data from the included studies were extracted and assessed for risk of bias.

RESULTS

Eleven studies were included. The sample size ranged from 12 to 96 subjects. The male to female ratio was 0 to 25%. The mean length of follow-up was 4 months. Occlusal splint had a positive effect on mandibular movements in all included studies. Seven studies showed a positive effect of occlusal splint on chronic pain reduction and pain intensity, while two others showed improvement of temporomandibular joint clicking sounds and locking of the jaws. Moreover, improvements in mouth opening, depression, and anxiety symptoms, were reported in four studies.

CONCLUSIONS

An occlusal splint can be considered as a non-invasive treatment approach for patients with TMD, especially those with signs and symptoms of restriction of mandibular movement and pain. Moreover, the present findings highlighted an urgent need of a standardised consensus regarding the prognostic evaluation of TMD.

Accuracy and its impact on fit of injection molded, milled and additively manufactured occlusal splints

Occlusal devices to reduce symptoms of bruxism and temperomandibular disorders can nowadays be manufactured in a digital workflow but studies comparing the accuracy of those occlusal devices are still limited. Therefore, the aim of this investigation was to investigate the accuracy of injection molding compared with four computer-aided design (CAD) and computer-aided manufacturing (CAM) techniques for the manufacturing of occlusal devices. In addition, the number of contact points and retention were evaluated to assess clinical relevance. A conventional workflow consisting of alginate impression, wax-up, and injection molding (IM) and digital workflows including intraoral scanning, digital design, and subtractive manufacturing (SM) or additive manufacturing by using stereolithography (SLA), digital light processing (DLP), and material jetting (Polyjet) were investigated. Sixteen splints were fabricated with each method. The intaglio surfaces of the splints were laser scanned and superimposed with the reference data sets to analyze the surface deviations. In addition, the number of contact points after repositioning the splints on the reference model was evaluated with occlusal foil. Finally, the retention was measured in a tensile test. One-way ANOVA with post hoc Tukey tests were used for statistical analyses (α = .05). IM and SM splints demonstrated the highest manufacturing accuracy without significant differences to each other (P > .985). Additive manufactured splints revealed greater deviations with equal results for SLA and Polyjet (P > .949) and significantly higher deviations for DLP compared to all other groups (P < .002). Comparable retention force was measured for IM, SM, and SLA (P > .923), whereas Polyjet splints showed the greatest variability. IM and SM splints presented the most contact points (P = .505). Additive manufactured splints demonstrated fewer contacts without significant difference to each other (P > .116). It can be concluded, that there is no difference in manufacturing accuracy, retention, and number of contacts between IM and SM splints. AM splints demonstrated higher, however, clinically acceptable deviations.

Accuracy of CAD/CAM-fabricated bite splints: milling vs 3D printing

Objectives

The aim of this study was to investigate the accuracy of CAD/CAM-fabricated bite splints in dependence of fabrication method (milling vs 3D printing), positioning (horizontal vs vertical), selection of material, and method of deviation measurement.

Materials and methods

Bite splints were 3D-printed in either horizontal or vertical position (n = 10) using four different resins (Dental LT, Ortho Clear, Freeprint Splint, V-Splint). As control, ten bite splints were fabricated by CNC milling (ProArt CAD Splint). The splints were scanned and deviations between the CAD-file (trueness) and between each other within one group (precision) were measured by two different software applications and methods (cloud-to-cloud vs cloud-to-mesh). Data were analyzed using univariate analysis, Kolmogorov-Smirnov, Kruskal-Wallis, and Mann-Whitney U tests.

Results

The highest impact on accuracy was exerted by the selection of the material (trueness: η_P² = 0.871, P < 0.001; precision: η_P² = 0.715, P < 0.001). Milled splints showed the highest trueness (P < 0.01) but not the highest precision at the same time. Horizontally positioned 3D-printed bite splints showed the least deviations in terms of trueness while vertical positioning resulted in the highest precision. The cloud-to-cloud method showed higher measured deviations than the other methods (P < 0.001–P = 0.002).

Conclusion

Milled splints show higher trueness than 3D-printed ones, while the latter reveal higher reproducibility. The calculated deviations vary according to the measurement method used.

Clinical relevance

In terms of accuracy, milled and 3D-printed bite splints seem to be of equal quality.

In vitro study on the influence of postpolymerization and aging on the Martens parameters of 3D-printed occlusal devices

STATEMENT OF PROBLEM

Additive manufacturing has been proposed for the fabrication of occlusal devices. However, information about the mechanical properties of additively manufactured devices is lacking.

PURPOSE

The purpose of this in vitro study was to evaluate the influence of the postpolymerization unit and artificial aging on the Martens hardness (HM) and indentation modulus (E_IT) of different 3D-printed materials in comparison with a conventionally milled material.

MATERIAL AND METHODS

Thirty disks (20 mm in diameter and 5 mm in thickness) were additively manufactured (D20 II, Rapidshape & Form 2) for each 3D-printed material (NextDent Splint, Formlabs Dental LT Clear, and Freeprint Splint). As a control, 10 disks of the same thickness were cut from a conventionally milled material (Temp Premium). Each specimen was measured for HM and E_IT (ZHU 0,2) after fabrication. The specimens were stored in water at 37 °C and measured again after 2 and 4 weeks. The data were analyzed statistically by using the Kruskal-Wallis, Mann-Whitney U, and Wilcoxon tests (adjusted by Bonferroni correction α=.05/27=.002).

RESULTS

The highest influence on HM parameters was shown by artificial aging (partial eta squared: HM: η_P²=0.840, E_IT: η_P²=0.855, P<.001), followed by the material (HM: η_P²=0.690 E_IT: η_P²=0.845, P<.001) and the postpolymerization unit (HM: η_P²=0.649, E_IT: η_P²=0.778, P<.001). Initial HM values ranged from 147 ±8.11 N/mm² for Formlabs postpolymerized in Otoflash to 89.5 ±8.55 N/mm² for Detax postpolymerized in the Labolight unit. E_IT values ranged from 3.92 ±0.061 kN/mm² for Formlabs postpolymerized in Otoflash to 2.48 ±0.212 kN/mm² for Detax postpolymerized in the Labolight unit. In general, HM and E_IT values decreased after water storage, whereas the values remained unchanged for the control group.

CONCLUSIONS

HM parameters of additively manufactured occlusal devices depend on postpolymerization strategy. Otoflash and Printbox result in higher HM and E_IT values. The 3D-printed materials are more prone to artificial aging than the control group, which brings into question their long-term service.

The course of pain intensity and frequency of adolescents treated because of temporomandibular disorders: A long-term follow-up

OBJECTIVES

To evaluate the course of pain intensity and frequency related to temporomandibular disorders (TMDs) 15 years (range 5-21 years) after having received TMD treatment as adolescents due to frequent (at least once a week) TMD pain in two controlled trials.

MATERIALS AND METHODS

In the first trial, subjects (n = 122) were randomly allocated to either information only, received in a control condition (Co), or information and an occlusal appliance (OA) versus relaxation therapy (RT). In the second trial, including 64 subjects, nonresponders to OA or RT were subsequently allocated to the alternate treatment (ST). All study participants having completed the trials (n = 167) were invited to a long-term follow-up evaluations, with a response rate of 69.5% (n = 116). Patient-reported outcomes of TMD-related frequency and intensity were appraised relative to baseline data and short-term outcomes as observed in the two trials by use of general linear mixed model and generalized estimation equation statistics.

RESULTS

A significantly higher proportion of participants treated with OA and in the combined RT/Co condition than those in the ST group, reported a frequency level of TMD pain less than once week at post-treatment and the long-term follow-up. Adolescents treated with OA showed significantly lower TMD pain intensity levels post-treatment than those in the other two treatment conditions. While no difference between the OA and the RT/Co conditions was found in the long-term follow-up, participants in these two conditions were significantly more improved than those in the ST group.

CONCLUSION

Adolescents treated with an OA clearly showed better outcome with regard to intensity and frequency in a long-term follow-up of TMD pain than those treated with RT and ST for nonresponders. These latter individuals need special clinical attention and more effective supplementary treatment methods to be developed.

Decreased mandibular cortical bone quality after botulinum toxin injections in masticatory muscles in female adults

This study aimed to clarify how masticatory muscle atrophy induced by botulinum toxin (BTX) injection affects cortical bone quality of the mandible using 3D modeling technology. A total of 39 young (26.9 ± 6.0 years) and 38 post-menopausal (55.3 ± 6.3 years) females were included. Computed tomography (CT) images were obtained before and after 12 months of treatment. Predictor variables were application of a stabilization splint, and/or two times of BTX injection in the bilateral temporalis and masseter muscles within a six-month interval. Outcome variables were changes in average Hounsfield units (HU) and cortical thickness of region of interest (ROI). 3D mandibular models were reconstructed using CT images, and models were used to calculate average HU and cortical thickness of ROIs, including inferior half of the lateral surface of ascending ramus, coronoid process, and temporomandibular joint condyle. Cortical bone quality at muscle insertion site was influenced by decreased muscle thickness but seemed not to be affected by decreased functional loading. Reduced functional loading seemed to influence cortical bone quality of the condyles. These effects were more remarkable in post-menopausal females. Hence, decreased masticatory muscle thickness may lead to alterations of the mandibular cortical structures, especially in post-menopausal females.

Comparison of acupuncture on specific and non-specific points for the treatment of painful temporomandibular disorders: A randomised controlled trial

BACKGROUND AND OBJECTIVE

The aim of this single-centre, two-arm, parallel-group, double-blinded, randomised controlled trial was to investigate the disputed specific effectiveness of acupuncture by comparing acupuncture on specific and non-specific points among patients with non-chronic, painful TMDs.

METHODS

Following predefined eligibility criteria, 49 consecutive patients of both sexes were recruited to the study. All subjects were diagnosed with a non-chronic (Graded Chronic Pain Scale grade <3) painful TMD, as assessed using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Patients were randomly assigned to group A (acupuncture on specific points) or group B (acupuncture on non-specific points) after the initial examination (T0). Both acupuncture treatment sessions were conducted by a trained dentist once a week for four weeks. The examination was repeated five weeks (T5) after T0 by one calibrated examiner who was unaware of the study groups. Characteristic pain intensity (CPI) was evaluated as the main outcome criterion and compared between times and treatment groups by means of non-parametric tests (significance level set at P = .05). Secondary outcomes comprised the maximum corrected active mouth-opening without pain (MAO); patients' expectations regarding acupuncture treatment and pain development; depressivity; and oral health-related quality of life (OHRQoL).

RESULTS

A total of 41 patients (38 female) successfully completed the study (mean age: 40.17 ± 16.61). The two groups did not differ significantly at any time in terms of age and CPI. However, CPI was significantly (P < .05) lower at T5 than at T0 for both groups (29.66 and 30.35% lower in group A and group B, respectively). An increase in MAO was observed at T5 for both groups but was significant for group B only (P = .016). All patients had positive expectations of acupuncture therapy, and the two groups did not differ significantly at T5 with regard to the extent to which their expectations had been fulfilled by the treatment (P = .717). Comparison of T0 and T5 showed a statistically significant reduction of depressivity for group A (P = .0205), but no significant change for group B (P = .329). At T5, OHRQoL had improved significantly for both groups (group A, P = .018; group B, P < .001) compared with at T0.

CONCLUSIONS

Acupuncture on both specific and non-specific points reduces the non-dysfunctional pain of TMD patients. The effect of acupuncture on painful TMD cannot be attributed to the specific point selection.

Anterior open bite due to idiopathic condylar resorption during orthodontic retention of a Class II Division 1 malocclusion

A common dilemma when treating anterior open bite is understanding its etiology. Idiopathic condylar resorption (ICR) can cause open bite in affected individuals. Although it is prudent to not treat patients with ICR until active resorption has ceased, orthodontists may begin treating them because anterior open bite from ICR may not appear before or during their orthodontic treatment. This article reports a 12-year-old female who was diagnosed with ICR 10 months after completion of her orthodontic treatment for a Class II Division 1 malocclusion. When a young patient with a high mandibular angle and previous skeletal or dental Class II malocclusion returns with an open bite during the retention phase, the patient's condyles must be carefully examined to determine whether any temporomandibular joint disorder, such as ICR, is present. Currently, the controversy over the cause and the cure for ICR is continuing to challenge orthodontists in diagnoses and treatments. Orthodontists should closely monitor and offer informed treatment options to patients with risk factors for ICR or signs of its pathology that might develop at any stage of orthodontic treatment, including the retention period.

Long-term Effectiveness of Occlusal Splint Therapy Compared to Placebo in Patients with Chronic Temporomandibular Disorders

Purpose

The aim of this study was to compare long-term effectiveness of stabilization splint (SS) with that of placebo splint (PS) in chronic TMD patients and to investigate differences in treatment outcomes based on diagnostic subgroups [disc displacement (DD)/myofascial pain (MP)].

Materials and Methods

Thirty-four female participants, diagnosed with chronic TMD, were classified in groups: one provided with SS and other with PS and were followed for six months. Treatment outcomes included spontaneous pain [visual analogue scale (VAS)], self-perceived quality of life (OHIP-14), pain-free maximal mouth opening (MCO), maximal mouth opening (MMO), level of perceived stress (PSS), characteristic pain intensity [graded chronic pain scale (GCPS)], and functional jaw limitation [jaw functional limitation scale (JFLS)].

Results

Baseline characteristics did not differ significantly between the two groups (p>0.05). After six months of treatment the changes in spontaneous pain and OHIP-14 scores differed significantly between treatment groups (p=0.004, p=0.02 respectively), with greater reduction in SS compared to the PS group. Pain-free maximal mouth opening did not change significantly over time, however MCO values differed significantly between the two treatment groups, with greater overall values in the SS compared to the PS group (p= 0.046), as well as between TMD subgroups, with greater overall values in MP compared to DD patients (p= 0.03). In the SS group, significant difference in JFLS categories was found between baseline and after 6 months of treatment in all except emotional and verbal expression (mastication p=0.00015; vertical jaw mobility p=0.00018). No such changes in JFLS categories were observed in the PS group.

Conclusions

During 6-month period, SS was more effective than PS in reducing spontaneous pain and improving self-perceived quality of life and functional limitations of the lower jaw. Moreover, significantely higher values of pain-free mouth opening were observed in patients treated with stabilization splint. While placebo might be partly responsible for improving the symptoms of TMD, it seems that itcannot maintain a continual long-term positive therapeutic effect.

Instant reduction in postural sway during quiet standing by intraoral dental appliance in patients with Whiplash associated Disorders and non-trauma neck pain

OBJECTIVES

This study tested the hypothesis that modulation of jaw sensorimotor control by intraoral dental appliance can reduce postural sway during quiet standing and hence improve standing balance, in patients with whiplash associated disorders (WAD) and non-trauma neck pain.

DESIGN

Postural sway during quiet standing with feet together was examined in 54 WAD patients (40 females) and 10 non-trauma patients (8 females) using wireless 3D movement recording technique. Recordings were performed alternating without and with intraoral dental appliance, and with closed eyes and open eyes, respectively. In this protocol the participants served as their own controls. A reference group of 30 healthy subjects (17 females) was also recorded. Each recording lasted 120 s, followed by 3-5 min of rest. Speed, acceleration and perimeter of postural sway area were documented.

RESULTS

In the patients, but not in the healthy group, the intraoral dental appliance instantly and significantly reduced standing postural sway in recordings with closed and open eyes.

CONCLUSIONS

The prompt reduction in standing postural sway from intervention by intraoral dental appliance i.e. improved standing balance, suggests a potent effect on the postural control system by modulation of the jaw sensorimotor system, probably involving reflex transmission. The result opens for new insight into mechanisms behind postural control and the pathophysiology of balance disorders, and adds to the knowledge on plasticity of the nervous system. It may help developing new procedures for assessment and management of impaired balance in WAD and non-trauma neck pain patients.

The Effect of Flat Dual-Cure Stabilizer Occlusal Splint in Pain Relief of Individuals Suffering from Migraine Headaches

Background:

No study on the effect of dual-cure stabilizer splint without canine ramp in migraine patients is present.

Objective:

This study was conducted to determine the effects of maxillary flat dual-cure stabilizer occlusal splint on severity, frequency and episodes of headaches in individuals suffering from a migraine.

Methods:

In this interventional clinical trial, 30 eligible patients were divided into 2 groups (case and control); each group consisted of 8 men and 7 women. Dual-cure stabilizer splint was made for patients in the case group and they used the adjusted splint 20 hours a day for 6 weeks. The severity, frequency and episodes of migraine attacks before and after using the splint were determined. For grading pain, severity visual analogue scale was used. The data were analyzed using SPSS 20 and Kolmogorov-Smirnov test and paired t-test.

Results:

The severity, frequency, and episodes of migraine attacks before and after using the splint were reduced by 56%, 68%, and 72%, respectively. The reduction was statistically significant (p < 0.05).

Discussion:

Despite the effect of occlusal devices on the migraine disorder is controversial, the most researchers agree that using these appliances can be effective in reducing headache in migraine patients.

Conclusion:

Given the favorable effects of dual-cure stabilizer splint on reducing the severity, frequency and episodes of migraine headaches, the device can be used as an effective alternative therapy besides common pain-relieving methods.

Scoping review of systematic review abstracts about temporomandibular disorders: Comparison of search years 2004 and 2017

INTRODUCTION

The purposes of this study were to determine how many systematic reviews and meta-analyses relating to temporomandibular disorders (TMDs) had been published as of 2017 compared with those published as of 2004 and then to summarize the findings, based on an analysis of the abstracts from those studies.

METHODS

A PubMed search was initiated on May 1, 2017. There were 2 separate searches. The first search was for the topic, "temporomandibular disorders." The second search was for "temporomandibular disorders and published in the Cochrane database." The number and the topic category of reviews for 2017 were compared with those published as of 2004.

RESULTS

There were 120 relevant TMD systematic reviews found in search year 2017: 110 from the PubMed and 10 from the Cochrane searches. By comparison, there were only 8 TMD systematic reviews published in 2004. The abstracts for all 120 reviews indicated increased roles of genetics and psychosocial factors in the etiology of TMD. The future of TMD diagnoses appears to be toward various psychosocial and cellular tests, along with brain neuroimaging. The reviews on the topic of "treatment" supported conservative, noninvasive, reversible therapies, with a trend toward more targeted individual strategies.

CONCLUSIONS

There were only 8 TMD systematic reviews published in 2004 compared with 110 in 2017. Overall, the trend has been in the direction of better diagnostic procedures, more scientific concepts of etiology, and more conservative treatments for TMD.

Comparison of amitriptyline with stabilization splint and placebo in chronic TMD patients: a pilot study

Objective of work

The authors conducted a clinical study to evaluate the effectiveness of amitriptyline in treatment of chronic TMD patients and to compare treatment results with stabilization splint.

Materials and Methods

Twenty-one patients with chronic TMD were included and randomly distributed into 3 groups: patients in Group A received amitriptyline, patients in Group B received placebo, and those in Group C were treated with stabilization splint. Treatment outcomes (pain assessed by a visual analogue scale (VAS), maximal comfortable mouth opening (MCO) and oral health related quality of life (OHIP-14)) were taken at baseline (before treatment), and at 1^st, 6^th and 12^th week of treatment.

Results

No statistically significant differences between the groups at baseline were found (p>0.05). VAS scores improved significantly in Group A (F=11.326, p=0.002, effect size =0.791) and in group C (F=7.343, p=0.005, effect size=0.647). Mean OHIP-14 scores decreased significantly only in Group A (F=4.417, p=0.036, effect size =0.596). In Group B, VAS and OHIP-14 scores did not change significantly over time. Subjects in Group C had a significant change in MCO relative to Group A and Group B.

Conclusion

From this pilot study it can be concluded that the use of low doses of amitriptyline for a period of 12 weeks is effective for pain management and quality of life improvement in chronic TMD patients. Stabilization splint demonstrated superiority in the management of limited mouth opening during the same period.

Assessment of the Short-Term Effectiveness of Kinesiotaping and Trigger Points Release Used in Functional Disorders of the Masticatory Muscles

Chronic face pain syndrome is a diagnostic and therapeutic problem for many specialists, and this proves the interdisciplinary and complex nature of this ailment. Physiotherapy is of particular importance in the treatment of pain syndrome in the course of temporomandibular joint functional disorders. In patients with long-term dysfunction of masticatory muscles, the palpation examination can localize trigger points, that is, thickening in the form of nodules in the size of rice grains or peas. Latent trigger points located in the muscles can interfere with muscular movement patterns, cause cramps, and reduce muscle strength. Because hidden trigger points can spontaneously activate, they should be found and released to prevent further escalation of the discomfort. Kinesiotaping (KT) is considered as an intervention that can be used to release latent myofascial trigger points. It is a method that involves applying specific tapes to the patient's skin in order to take advantage of the natural self-healing processes of the body. The aim of the study was to evaluate the effect of the kinesiotaping method and trigger points inactivation on the nonpharmacological elimination of pain in patients with temporomandibular disorders. The study was conducted in 60 patients (18 to 35 years old). The subjects were randomly divided into two subgroups of 30 people each. Group KT (15 women and 15 men) were subjected to active kinesiotaping application. Group TrP, composed of 16 women and 14 men, was subjected to physiotherapy with the release of trigger points by the ischemic compression method. The results show that the KT method and TrP inactivation brought significant therapeutic analgesic effects in the course of pain-related functional disorders of the muscles of mastication. The more beneficial outcomes of the therapy were observed after using the KT method, which increased the analgesic effect in dysfunctional patients.

Similar treatment outcome in myofascial TMD patients with localized and widespread pain

OBJECTIVE

To study the outcome of oral appliance treatment in myofascial Temporomandibular disorder (TMD) patients with and without comorbid pain using pain site drawings.

MATERIAL AND METHODS

This randomized, controlled multicentre study comprised 65 myofascial TMD patients diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders. Pain-site drawings were filled in at the baseline examination. The patients were treated with oral appliances. Treatment outcome was followed up for 1 year and analysed according to the recommendations by the Initiative on Methods, Measurement and Pain assessment in Clinical Trials (IMMPACT) on an intent-to-treat basis. The data were analysed for two pain profiles, localized pain (face and head, n = 26) versus widespread pain group (pain sites outside the face and head, n = 39).

RESULTS

Statistically significant improvement was registered within both groups for all outcome variables (characteristic pain intensity, 30% pain reduction of worst reported pain, graded chronic pain, depression, and somatization scores) during the follow-up with only small differences between the groups.

CONCLUSIONS

Oral appliance treatment had a positive effect on all outcome measures during the 1-year follow-up in patients suffering from myofascial TMD pain, regardless of whether the pain was localized or widespread. Multiple pain sites seemed to have surprisingly little influence on the outcome variables. However, some indications of more challenges when treating patients with widespread pain compared to local pain could be observed. Pain-site drawings seem to be useful in the clinical situation and could support the clinicians in decision-making regarding treatment planning.

Long-term treatment outcome for adolescents with temporomandibular pain

OBJECTIVES

This study aims to evaluate long-term, self-perceived outcome in adulthood for individuals treated as adolescents for temporomandibular disorder (TMD) pain in two previous randomized controlled trials (RCTs).

MATERIALS AND METHODS

The study included 116 subjects (81% females) treated for frequent TMD pain in two separate RCTs 5-21 (M = 14.8, SD =4.9) years previously. Treatment consisted of occlusal appliance (OA) (n = 41, 35.3%) or relaxation training (RT) combined with information for the control (Co) group (n = 50, 43.1%), both compared to non-responders receiving additional, sequential treatment (ST) in a crossover study (n = 25, 21.6%). Participants answered a questionnaire on their experience of frequency and intensity of TMD pain impaired chewing capacity and daily social activities, help-seeking behaviour and treatment, general health, other pain, and depressive symptoms.

RESULTS

Older participants reported lower levels of frequency and intensity of TMD pain, impairment, and depressive symptoms, as well as better general health. Females reported more frequent and more intense TMD pain, greater impairment and more often reported 'other pain' compared to males. Non-responders receiving ST experienced significantly more TMD, and other pain and higher impairment levels compared to other groups. Those treated with an OA had sought additional treatment significantly less often since the RCTs than ST and RT/Co-treated individuals.

CONCLUSIONS

Adolescents treated with OA showed somewhat better sustained improvement over the extended follow-up period than those treated with RT/Co. Non-responders to treatment and females exhibited a poorer outcome. These groups need particular attention and extended or different treatments to achieve a better long-term outcome.

Myofascial Pain: Mechanisms to Management

More than 100 million adults in the United States have chronic pain conditions, costing more than $500 billion annually in medical care and lost productivity. They are the most common reason for seeking health care, for disability and addiction, and the highest driver of health care costs. Myofascial pain is the most common condition causing chronic pain and can be diagnosed through identifying clinical characteristics and muscle palpation. Management is focused on integrating patient training in changing lifestyle risk factors with evidence-based treatment. Understanding the cause, diagnosis, and management of myopain conditions will help prevent the impact of chronic pain.

Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects

Background

Psychological discomfort, physical disability and functional limitations of the orofacial system have a major impact on everyday life of patients with temporomandibular disorders (TMDs). In this study we sought to determine short and long term effects of stabilization splint (SS) in treatment of TMDs, and to identify factors influencing its efficacy.

Methods

MEDLINE, Web of Science and EMBASE were searched for randomized controlled trials (RCTs) comparing SS to: non-occluding splint, occlusal oral appliances, physiotherapy, behavioral therapy, counseling and no treatment. Random effects method was used to summarize outcomes. The effect estimates were expressed as odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval. Subgroup analyses were carried out according to the use of Research Diagnostic Criteria (RDC/TMD) and TMDs origin. Strength of evidence was assessed by GRADE. Meta-regression was applied.

Results

Thirty three eligible RCTs were included in meta-analysis. In short term, SS presented positive overall effect on pain reduction (OR 2.08; p = 0.01) and pain intensity (SMD -0.33; p = 0.02). Subgroup analyses confirmed SS effect in studies used RDC/TMD and revealed its effect in patients with TMDs of muscular origin. Important decrease of muscle tenderness (OR 1.97; p = 0.03) and improvement of mouth opening (SMD -0.30; p = 0.04) were found. SS in comparison to oral appliances showed no difference (OR 0.74; p = 0.24). Meta-regression identified continuous use of SS during the day as a factor influencing efficacy (p = 0.01). Long term results showed no difference in observed outcomes between groups. Low quality of evidence was found for primary outcomes.

Conclusion

SS presented short term benefit for patients with TMDs. In long term follow up, the effect is equalized with other therapeutic modalities. Further studies based on appropriate use of standardized criteria for patient recruitment and outcomes under assessment are needed to better define SS effect persistence in long term.

Magnetic resonance and sonographic imagings of masticatory muscle myalgia in temporomandibular disorder patients

This article reviews recently published studies investigating the MRI and sonographic diagnosis of masticatory muscle myalgia in temporomandibular disorder patients. The MRI and sonographic features of muscle after treatment are also discussed. Literature published within the last 15 years was obtained from the PubMed database using the following Mesh terms: magnetic resonance imaging (MRI) or sonography, masticatory muscle pain, and treatment. MRI and sonography enable accurate visualization and evaluation of the masticatory muscles, thereby increasing our understanding of pathology and cause of pain associated with these muscles. Although therapeutic efficacy is often evaluated based on clinical findings, MR and sonographic imaging studies may also be valuable.

Counseling and oral splint for conservative treatment of temporomandibular dysfunction: preliminary study

Abstract Introduction Temporoamndiular Disorders (TMD) involve the masticatory muscles, temporomandibular joint (TMJ) or both. The most common symptom is pain, which is usually located in the muscles of mastication, pre-auricular region, and / or ATM, especially during mandibular function. The main treatment for TMD is related to pain relief. Objective The purpose of this case report was to evaluate the reduction of pain symptoms using Visual Analogue Scale (VAS) of patients with TMD treated with counseling and use of occlusal splint (OS). Material and method 16 subjects had participated in this study, that was composed by 4 appointment with 7-day interval between each (CEP FOP / Unicamp – 137/2009). In the first, an examiner used the Research Diagnostic Criteria for Temporomandibular Disorders (RDC / TMD) to diagnose each patient and delivered a VAS to register the intensity of daily pain. In the second, counseling, molding of both dental arcs to fabricate the OS and the delivery of new VAS were performed. In the third, there was the installation and adjustment of the OS and the delivery of another scale, and in the last, possible adjustments on the OS were done. Data were analyzed by ANOVA two way and Tukey post-test at 5% significance level. Result There was significant difference when comparing the intensity of pain of individuals after installation of splint with the baseline data and after counseling (p = 0.05). Conclusion According to the result of this study, the treatment of TMD associating counseling occlusal splint is effective in reducing pain intensity.

Comparison of three different options for immediate treatment of painful temporomandibular disorders: a randomized, controlled pilot trial

OBJECTIVE

The purpose of this study was to compare the short-term effectiveness of three different types of immediate, non-pharmacological intervention for alleviation of the painful symptoms of temporomandibular disorders (TMD).

MATERIAL AND METHODS

Thirty-six patients (mean age 41.6 ± 16.7 years, 25 females) diagnosed with non-dysfunctional painful TMD received counselling and subsequently were randomly allocated to three treatment groups: patients in Group A received prefabricated oral splints with water-filled elastic pads (Aqualizer(®)), those in Group B were provided with vacuum-formed co-polyester oral splints and those in Group C were given appointments to receive Michigan-type hard splints. Clinical examination was conducted, at baseline and after 2 weeks, by use of the RDC/TMD. Current pain intensity was determined by evaluation of graded chronic pain status (GCPS) on a numerical rating scale (NRS). Active maximum mouth opening without pain (AMMOP) was also measured. Paired sample t-tests and one-way analysis of variance with a significance level of p ≤ 0.05 were conducted.

RESULTS

After 2 weeks, overall mean current pain was reduced by 41.95% (p < 0.001). Current pain reduction was significant for Group B (66.6%, p < 0.001) but not for Groups A (37.88%, p = 0.56) and C (22.29%, p = 0.26). After 2 weeks, current pain level for Group B was significantly lower than that for Group C (p = 0.041). Overall, there was a statistically significant increase of AMMOP (p = 0.01).

CONCLUSION

All therapeutic options were pain-reducing. The results from this study suggest that cost-effective and time-effective intervention of counselling combined with use of a vacuum-formed splint is a favourable option for initial, short-term treatment of painful TMD.

Comparative evaluation of clinical performance of different kind of occlusal splint in management of myofascial pain

Purpose:

To determine the efficacy of hard, liquid, and soft splints in the management of myofascial pain dysfunction syndrome.

Materials and Methods:

In this randomized clinical trial, 45 patients with myofascial pain were diagnosed and were randomly assigned into three groups of 15 patients each. Group 1 - subjects were given hard splint, Group 2 - soft splint, and Group 3 - liquid oral splint for 3 months. Subjective pain analysis using Modified Symptom Severity Index (Mod-SSI) and objective pain analysis muscle palpation was performed at 7 days, 1 month, 2 months, and 3 months after splint insertion. The changes in mean pain value by both methods, in all three groups, were analyzed with Tukey test and Kruskal–Wallis H-test, respectively (P < 0.05).

Results:

Both Mod-SSI and palpation scores showed statistically significant reduction in pain for all three groups at the end of 3 months. However, the hard splints proved to be very effective in a shorter period of time, followed by liquid splints and finally soft splints.

Conclusion:

The result of this study advocates the use of any one of the three types of the occlusal splints in the therapeutic management of myofascial pain due to temporomandibular disorders.

Efficacy of stabilisation splint therapy combined with non-splint multimodal therapy for treating RDC/TMD axis I patients: a randomised controlled trial

Stabilisation splint therapy has long been thought to be effective for the management of temporomandibular disorders (TMD). However, the superiority of stabilisation splint therapy compared to other TMD treatments remains controversial. The aim of this study was to determine the efficacy of stabilisation splint therapy combined with non-splint multimodal therapy for TMD. A total of 181 TMD participants were randomly allocated to a non-splint multimodal therapy (NS) group (n = 85) or a non-splint multimodal therapy plus stabilisation splint (NS+S) group (n = 96). Non-splint multimodal therapy included self-exercise of the jaw, cognitive-behavioural therapy, self-management education and additional jaw manipulation. Three outcome measurements were used to assess treatment efficacy: mouth-opening limitation, oro-facial pain and temporomandibular joint sounds. A two-factor repeated-measures analysis of variance (anova) was used to evaluate the efficacy of the two treatment modalities (NS vs. NS+S), and Scheffe's multiple comparison test was used to compare the treatment periods. Subgroup analyses were performed to disclose the splint effects for each TMD diagnostic group. All three parameters significantly decreased over time in both groups. However, there were no significant differences between the two treatment groups in the total comparison or subgroup analyses; an exception was the group with degenerative joint disease. No significant difference between the NS and NS+S treatment approaches was revealed in this study. Therefore, we conclude that the additional effects of stabilisation splint are not supported for patients with TMD during the application of multimodal therapy.

Can sonographic features be efficacy predictors of robotic massage treatment for masseter and temporal muscle in patients with temporomandibular disorder with myofascial pain?

OBJECTIVE

The aim of this study was to detect sonographic predictors for the efficacy of massage treatment of masseter and temporal muscle in temporomandibular disorders (TMDs) patients with myofascial pain.

METHODS

Thirty-seven TMD patients with myofascial pain (6 men and 31 women, a median age of 45 years) were enrolled. An oral rehabilitation robot massaged the patient's masseter and temporal muscles with a standard massage pressure of 10 N for 16 min. The standard treatment protocol was set five sessions every 2 weeks. The median total duration of treatment was 9.5 weeks. Efficacy of treatment was evaluated based on maximum mouth opening and visual analog scale scores of muscle pain and daily life impediments. The intramuscular echogenic bands and elasticity index ratios of the masseter muscles were evaluated on sonographic or sonoelastographic images obtained before treatment and after the third and last treatment sessions.

RESULTS

The sonographic features detected different changes after the third treatment session between the therapy-effective and therapy-ineffective groups: in the therapy-effective group, the frequency of visibility of the distinct echogenic bands increased, and the elasticity index ratio decreased.

CONCLUSION

Sonographic features after the third treatment session may be useful as predictors of therapeutic efficacy.

Systematic review and recommendations for nonodontogenic toothache

Nonodontogenic toothache is a painful condition that occurs in the absence of a clinically evident cause in the teeth or periodontal tissues. The purpose of this review is to improve the accuracy of diagnosis and the quality of dental treatment regarding nonodontogenic toothache. Electronic databases were searched to gather scientific evidence regarding related primary disorders and the management of nonodontogenic toothache. We evaluated the level of available evidence in scientific literature. There are a number of possible causes of nonodontogenic toothache and they should be treated. Nonodontogenic toothache can be categorised into eight groups according to primary disorders as follows: 1) myofascial pain referred to tooth/teeth, 2) neuropathic toothache, 3) idiopathic toothache, 4) neurovascular toothache, 5) sinus pain referred to tooth/teeth, 6) cardiac pain referred to tooth/teeth, 7) psychogenic toothache or toothache of psychosocial origin and 8) toothache caused by various other disorders. We concluded that unnecessary dental treatment should be avoided.

Temporomandibular disorders. Part 2: conservative management

Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables.

The efficacy of a specific stabilization splint

BACKGROUND

The use of a Tanner type stabilization splint, fabricated on a leaf gauge articulation for the treatment of patients with disc displacement without reduction, is lacking in the literature.

OBJECTIVES

The purpose of the study is to collect non-controlled, therapy-related observations; in other words, to demonstrate the efficacy of this appliance for the treatment of patients with disc displacement without reduction.

METHODS

The study enrolled 55 patients, 5 men, and 50 women, with the clinical diagnosis disc displacement without reduction, 42 with and 13 without limited mouth opening. All patients received a splint in the musculoskeletally stable centric relation (CR) position. Mouth opening, clinical performance, and the timeframe of splint treatment were assessed.

RESULTS

For 37 patients with a disc displacement without reduction with limited opening, the largest increase in mouth opening (9.5 +/- 5.6 mm) occurred in the first week (7.9 +/- 2.5 days). No occlusal adjustment of the splint was needed during the treatment sequence. For three patients, treatment took up to 3 months (8.1%), for 13 patients, between 3 and 6 months (35.1%), and for 17 patients, within a year (45.9%), making a total of 89.1% successfully treated patients. Out of 50 patients, 29 had a total resolution of signs and symptoms, whereas 21 patients still suffered from solitary temporomandibular disorder (TMD) signs.

CONCLUSION

A Tanner type stabilization splint, fabricated in the musculoskeletally stable CR position, appears to be an effective and efficient means for the treatment of patients with disc displacement without reduction. Its efficacy makes it eligible to be tested in a randomized controlled trial.

CLINICAL IMPLICATIONS

The efficacy of this specific splint, fabricated in the musculoskeletally stable CR position, makes it a promising tool to treat TMD patients with disc displacement without reduction.

The influence of different registration positions on condyle displacement in symptomatic patients

OBJECTIVE

This study aimed to evaluate effects of different registration positions on the condyle-disk position changes in the mandibular fossa in symptomatic individuals.

STUDY DESIGN

Vertical and sagittal condyle position and thickness of the bilaminar zone were measured by magnetic resonance imaging during maximal intercuspation (MI) and with jigs in Gothic arch tracing guided centric relation (DIR method [Dynamics and Intraoral Registration]) and retruded contact position (RCP). Participants were 26 patients seeking treatment for temporomandibular disorders. Condyle and disk position in the fossa were calculated in the parasagittal plane.

RESULTS

Significant differences were found for MI, DIR, and RCP for thickness of bilaminar zone and sagittal condyle position, dependent on diagnosis and registration position for vertical and sagittal condyle position and thickness of bilaminar zone.

CONCLUSIONS

DIR position ensures the widest posterior space for the retrodiskal tissues and the slightest sagittal difference between condyle zenith and glenoid fossa.