Short-term effectiveness of conservative therapies in pain, quality of life, and sleep in patients with temporomandibular disorders: A randomized clinical trial

Synthesis of temporomandibular disorders management intervention outcomes for development of core outcome sets: A systematic review

INTRODUCTION

The selection of appropriate outcomes in clinical trials and systematic reviews is a crucial factor in determining the results that are useful, reliable, and relevant for both patients and healthcare professionals. Clinicians and researchers have been encouraged to develop and apply core outcome sets (COS) to minimise the discrepancy between studies.

AIM

This systematic review is the first phase of the COS development project for clinical trials in temporomandibular disorders (COS-TMD). It aims to identify and synthesise the outcomes used in the randomised controlled trials (RCT) that evaluated the effectiveness of interventions used in TMD management.

MATERIALS AND METHODS

An electronic search was performed in several databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library and EMBASE. The eligibility criteria comprised RCT that applied any intervention to treat temporomandibular joint disorders or masticatory muscle disorders. The identified outcomes were categorised according to domains of the Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT).

RESULTS

The electronic search resulted in 1606 studies. After removing duplicates and applying the eligibility criteria, 106 RCT were included. A total of 43 studies evaluated masticatory muscle disorders, 27 evaluated temporomandibular joint disorders, and 36 analysed mixed TMD.

CONCLUSIONS

The evaluation showed significant variability in the types of outcomes and their measurement instruments. In addition, some domains such as physical and emotional functioning, participant ratings of global improvement and adverse events have been neglected when determining the effectiveness of treatments for TMD.

Skeletal, dentoalveolar and soft tissue changes after stabilization splint treatment for patients with temporomandibular joint disorders

BACKGROUND

Temporomandibular disorder (TMD) is a grouping of heterogeneous disorders with multifactorial origins. Stabilization splints (SS) have demonstrated an acceptable treatment effect in TMD. The possible changes at the skeletal, dental, and soft tissue levels need to be addressed to evaluate the benefit/risk ratio of this therapeutic procedure. Accordingly, this study aimed to three‑dimensionally evaluate skeletal, dentoalveolar and soft tissue changes after SS treatment for patients with TMD.

METHODS

This retrospective study included 74 adult patients with myofascial and/or intra-articular disorders (25 males and 49 females), with an average age of 22.88 ± 4.8 years, who underwent SS treatment. Pre- and post-treatment Cone beam computed tomography were analysed using Invivo 6.0.3 software. The primary outcome was the vertical skeletal and dentoalveolar changes, while the secondary outcomes were the anteroposterior skeletal, dentoalveolar and soft tissue changes. Paired t-test and Wilcoxon rank sum test were used for statistical analyses.

RESULTS

For the primary outcome; skeletally, there was a significant increase in mandibular plane inclination (difference: 0.82°±1.37), decrease facial height ratio (difference: 0.45%±1.07) and at the dentoalveolar level, the inclination of the functional (FOP-SN, FOP-FH) and bisecting (BOP-SN, BOP-FH) occlusal planes exhibited a significant increase too (difference: 0.38 ± 1.43°, 0.49 ± 1.62°, 0.44 ± 1.29° and 0.41 ± 1.17°, respectively) and also a decrease in the overbite (difference: -0.54 ± 0.83). For the secondary outcomes; there was a significant decrease in mandibular position (SNB) (difference: 1.60 ± 1.36°) and increase in the overjet (difference: 0.93 ± 1.04, p < 0.001) and a significant lower lip retrusion (difference: 0.33 ± 1.01 mm p < 0.01), was observed too.

CONCLUSIONS

SS therapy resulted in significant vertical skeletal and dentoalveolar changes that were manifested mainly by facial height ratio, mandibular and occlusal plane changes, and to a lesser extent, significant anteroposterior skeletal, dentoalveolar, and soft tissue changes in the form of mandibular position, increased overjet and a more retrusive lower lip. These changes should be considered during patients' selection prior to initiating SS therapy.

Changes in oral health-related quality of life after self-care treatment in patients with myofascial pain

OBJECTIVE

The aim of this study was to evaluate the changes in oral health-related quality of life (OHRQoL) of patients with myofascial pain treated by means of self-care measures.

METHODS

Fifteen patients with myofascial pain had OHRQoL evaluated by the Oral Health Impact Profile (OHIP-TMD) questionnaire and were instructed for self-care measures verbally and with a printed guide in the first consultation (T0), after 30 days (T1) and 60 days (T2). Paired t-test was performed to evaluate changes through time.

RESULTS

OHIP-TMD scores were 29.3 (SD 10.2) at T0, 18.9 (SD 11.2) at T1, and 15.9 (SD 10.7) at T2. There was a reduction of scores related to the OHIP-TMD domains of functional limitation, physical pain, psychological and social inability and incapacity (T1 and T2), and psychological discomfort (T2).

CONCLUSION

Self-care measures had positive effects on the myofascial pain treatment, reducing physical pain generated by TMD and improving patients' OHRQoL.

Validity and Reliability of the Turkish Version of Mandibular Function Impairment Questionnaire

OBJECTIVE

To assess the validity and reliability of the Turkish version of the Mandibular Function Impairment Questionnaire (MFIQ-TR).

METHODS

Included in this study were 248 patients diagnosed with temporomandibular disorder (TMD) according to Diagnostic Criteria for TMD Axis I protocol. Construct-related validity was evaluated through internal and external construct validity; convergent and divergent validities were evaluated by the average variance extracted (AVE), composite reliability (CR), and bivariate correlations between factors. Reliability was assessed by internal consistency and test-retest reliability.

RESULTS

All items of the MFIQ-TR had content validity and factor loadings above 0.5. The model statistics indicated a good fit. The convergent validity was very good (AVE > 0.5 and CR > 0.7), and the discriminant validity was satisfied. Internal consistency and test-retest reliability of the MFIQ-TR were excellent.

CONCLUSION

The MFIQ-TR is a valid and reliable instrument for evaluating the impairment of mandibular function in Turkish patients with TMD.

Additional splint therapy has no superiority in myogenic temporomandibular disorders: A systematic review and meta-analysis of randomized controlled trials

Purpose Temporomandibular disorders (TMDs) are frequent stomatological disorders. However, their treatment is controversial. Therefore, we compared the efficacy of combination therapy (splint therapy along with physiotherapy, manual therapy, and counseling) with physiotherapy, manual therapy, and counseling alone. The extent of mouth opening and pain perception were the outcomes.Study selection Systematic searches for English publications were performed using four major literature databases (Cochrane Library, EMBASE, PubMed, and Web of Science). We included randomized controlled trials. We calculated mean differences with 95% confidence interval (CI) for pain perception and maximum mouth opening (MMO) for the two groups. The Hartung-Knapp adjustment was used for cases comprising at least five studies.Results Six articles were included in the pain perception category, and four were reviewed for MMO at baseline. Four articles assessed pain perception, and two assessed MMO at 1 month. Five articles were analyzed upon comparing pain perception at baseline and 1-month follow-up. The mean difference was -2.54 [95% CI: -3.38; to -1.70] in the intervention group and -2.33 [95% CI: -4.06; to -0.61] in the control group. Two articles were analyzed upon comparing MMO at baseline and 1-month follow-up. The mean difference in the intervention group was 3.69 [95% CI: -0.34; 7.72], whereas that in the control group was 3.62 [95% CI: -3.43; 10.67].Conclusions Both therapies can be used in the management of myogenic TMD. Due to the marginal differences between the baseline and 1-month values, our results could not confirm the efficacy of combination therapy.

Temporomandibular disorders and the use of traditional and laser acupuncture: a systematic review

OBJECTIVE

To evaluate current studies to establish and compare the efficacy of traditional and laser acupuncture in reducing the signs and symptoms of temporomandibular disorders (TMD).

METHODS

PubMed, Cochrane, Scopus, and Web of Science databases were searched. Clinical, controlled, and randomized trials written in English and having used traditional or laser acupuncture as therapy for TMD and RDC/TMD or DC/TMD as a diagnostic criterion for TMD were included.

RESULTS

Six studies that evaluated the intensity of pain and the level of mouth opening of the patients submitted to acupuncture were selected, and all showed improvement. However, similar results were also observed in the groups treated with occlusal splint and placebo acupuncture. Only one study evaluated laser acupuncture and showed a higher proportion of patients with remission of symptoms in the experimental group.

CONCLUSION

The traditional acupuncture seems to relieve the signs and symptoms of TMD, as well as laser acupuncture when associated with occlusal splint. However, more rigorous and high-quality clinical trials are needed.

Effects of Jaw-Opening Exercises with/without Pain for Temporomandibular Disorders: A Pilot Randomized Controlled Trial

This study aimed to evaluate the effects of jaw-opening exercises with and without pain on temporomandibular disorders (TMDs), specifically in relation to pain intensity and range-of-mouth opening in patients with TMDs. Participants were randomly assigned to either the jaw-opening exercise with pain (JE w/pain) or the jaw-opening exercise without pain (JE w/o pain) groups, and each exercise was performed for eight weeks. TMDs pain intensity was assessed using a 100-mm visual analog scale (VAS), and the range-of-mouth opening was evaluated at the baseline (T0), 2 weeks (T1), 4 weeks (T2), and 8 weeks (T3). Of the 61 participants, 57 (JE w/pain group, n = 30; JE w/o pain group, n = 27) were included in the analysis. The range-of-mouth opening and TMDs pain intensity improved from T1 to T3 in both groups. The JE w/pain group showed significant differences at T3 compared to T1 (pain-free unassisted mouth opening, p = 0.006; jaw-opening pain, p = 0.014; chewing pain, p = 0.018). In addition, the JE w/pain group showed significantly greater changes in the maximum unassisted mouth opening at T2 and T3 than the JE w/o pain group (T2, p < 0.001; T3, p = 0.003). Thus, jaw-opening exercises, until the occurrence of pain, may be effective in patients with TMDs.

Factors associated with the oral health-related quality of life of patients with temporomandibular disorder at the final follow-up visit: a cross-sectional study

OBJECTIVES

To determine the oral health-related quality of life (OHRQoL) of temporomandibular disorder (TMD) patients at the final follow-up visit, and to investigate the associated factors.

MATERIALS AND METHODS

This cross-sectional study comprised 227 TMD patients. Dependent variable was OHRQoL determined by telephone interview using the 14-item Oral Health Impact Profile (OHIP-14) questionnaire after the final follow-up visit. Independent variables were collected from dental records, comprising age, sex, treatment duration, diagnosis, clinical parameters (mouth-opening distances), and pain perception. TMD patients were diagnosed as having masticatory muscle disorders (TMDM), temporomandibular joint (TMJ) disorders (TMDJ), or combined muscle and TMJ disorders (TMDC). Bivariate analyses and multivariable linear regression were used to analyze the factors associated with OHIP-14 scores.

RESULTS

Bivariate analyses demonstrated higher OHIP-14 scores in younger patients, females, having TMDC, and lower mouth-opening distance. Multivariable analysis demonstrated the association of higher OHIP-14 scores with being younger and having TMDC. Participants with TMDC demonstrated greater improvement in unassisted mouth-opening distance, compared with the other clinical diagnosis groups.

CONCLUSIONS

At the final follow-up visit, oral health impact problems were reported mainly in physical pain and psychological discomfort domains. Better OHRQoL was found in older, and TMDM or TMDJ patients.

Nonpharmacological Interventions for Pain in Patients with Temporomandibular Joint Disorders: A Systematic Review

This systematic review aimed to compare the efficacy of nonpharmacological therapies for painful temporomandibular joint disorders. The protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020171364). The search was performed on the electronic databases PubMed, Google Scholar, Clinical Trials, and Web of Science. The eligibility criteria were randomized controlled trials in patients diagnosed with painful temporomandibular joint disorders comparing the pain relief between conventional treatment and nonpharmacological therapies such as acupuncture, physiotherapy, low-level laser, and massage. Fourteen articles were included in this review. At the overall bias of the studies included, 71.42% exhibited some concerns and 28.57% had high risk. The efficacy of nonpharmacological interventions was found to be moderate in the short term and variable in the long term for pain reduction in patients with temporomandibular joint disorders. The evidence pointed out that acupuncture, laser therapy, and physiotherapy are potentially useful interventions for pain relief in patients with temporomandibular joint disorders. However, there is a lack of consistency and short-term follow-up in the studies to determine the lasting of such effect.

The Application of Manual Techniques in Masticatory Muscles Relaxation as Adjunctive Therapy in the Treatment of Temporomandibular Joint Disorders

Temporomandibular disorders (TMD) are primarily characterized by pain as well as disorders concerning the proper functioning of individual elements of the stomatognathic system (SS). The aim of the study was to compare the degree of relaxation of the anterior part of the temporal muscles and the masseter muscles, achieved through the use of post-isometric relaxation and myofascial release methods in patients requiring prosthetic treatment due to temporomandibular joint disorders with a dominant muscular component. Sixty patients who met the inclusion criteria were alternately assigned to one of the two study groups, either group I—patients received post-isometric relaxation treatment (PIR), or group II—patients received myofascial release treatment (MR). The series of ten treatments were performed in both groups. The comparative assessment was based on physiotherapeutic examination, a surface electromyography (sEMG) of the anterior temporal and masseter muscles and the intensity of spontaneous masticatory muscle pain, assessed using the Visual Analogue Scale (VAS). We observed a significant decrease in the electrical activity of examined muscles and a significant drop in the intensity of spontaneous pain in the masticatory muscles both in group I and II. There were no significant differences between groups. Both therapeutic methods may be used as successful forms of adjunctive therapy in the prosthetic treatment of TMD. The trial was registered with an international clinical trials register.

Comparative evaluation of occlusal splint therapy and muscle energy technique in the management of temporomandibular disorders: A randomized controlled clinical trial

Background:

Contradicting evidence regarding the effects of occlusal splint therapy in the management of Temporomandibular disorder (TMD) and promising results shown by muscle energy technique.

Aim:

To determine and compare the effects of occlusal splint therapy, muscle energy technique, and combined treatment with education for self-management and counseling in the management of TMD.

Study Design and Settings:

Randomized clinical trial.

Methodology:

A total of 160 participants diagnosed with TMD according to Diagnostic Criteria/TMD axis I were randomly allocated into four treatment groups with equal allocation ratio using random numbers table. The main inclusion criteria were the presence of pain in the preauricular area, TMJ and/or muscles of mastication and maximum mouth opening <40 mm. Group A participants received muscle energy technique, Group B participants received occlusal splint therapy, Group C participants received combined treatment, and Group D participants received education for self-management and counseling (control). Control group treatment was provided to all the trial participants.

Statistical Analysis:

Intragroup comparison was made using Friedman test and Wilcoxon test while intergroup comparison was done using Kruskal–Wallis test and Mann–Whitney U test.

Results:

Intensity of pain on a visual analog scale and maximum mouth opening were measured at baseline, at 1 week, at 2 weeks, at 1 month, and after 3 months.

Conclusion:

Muscle energy technique, occlusal splint therapy and combined treatment significantly reduce pain compared to controls and muscle energy and combined treatment are superior to other groups for mouth opening improvements in patients with TMD.

Short-Term Effect of Scalp Acupuncture on Pain, Sleep Disorders, and Quality of Life in Patients with Temporomandibular Disorders: A A Randomized Clinical Trial

OBJETIVE

To evaluate the effects of Chinese scalp acupuncture in patients diagnosed with temporomandibular disorders (TMD) on pain, sleep, and quality of life (QOL), and compare these results with the results from traditional therapies.

METHODS

Sixty patients diagnosed with TMD using the research diagnostic criteria for temporomandibular disorders (RDC/TMD) were allocated into four treatment groups: counseling (C = 15), occlusal splint (OS = 15), scalp acupuncture (SA = 15), and manual therapy (MT = 15). Participants were re-evaluated within 1 month. Three questionnaires were used to access sleep disorders, QOL, and pain: The Pittsburgh Sleep Quality Index (PSQI), World Health Organization Quality of Life (WHOQOL-bref), and the Visual Analogue Scale (VAS), respectively. The data obtained were analyzed using the Statistical Package for the Social Science program (SPSS 22.0).

RESULTS

The SA group significantly improved pain (P = .015), as well as the OS (P = .01) and MT groups (P = .014). Only the OS (P = .002) and MT (P = .029) groups improved sleep. MT group significantly improved QOL in terms of the physical domain of the WHOQOL-bref (P = .011) and the OS group in the psychological domain (P = .012).

CONCLUSIONS

The scalp acupuncture proved to be another alternative for pain relief in patients with TMD, demonstrating positive results in the short term. However, it was not as effective in improving quality of life and sleep.

Temporomandibular Disorders: Current Concepts and Controversies in Diagnosis and Management

Temporomandibular disorders (TMD) are a group of orofacial pain conditions which are the most common non-dental pain complaint in the maxillofacial region. Due to the complexity of the etiology, the diagnosis and management of TMD remain a challenge where consensus is still lacking in many aspects. While clinical examination is considered the most important process in the diagnosis of TMD, imaging may serve as a valuable adjunct in selected cases. Depending on the type of TMD, many treatment modalities have been proposed, ranging from conservative options to open surgical procedures. In this review, the authors discuss the present thinking in the etiology and classification of TMD, followed by the diagnostic approach and the current trend and controversies in management.

Timing of arthrocentesis in the management of temporomandibular disorders: an integrative review and meta-analysis

The aim of this study was to assess the best timing to perform arthrocentesis in the management of temporomandibular disorders with regard to conservative treatment. A systematic search based on PRISMA guidelines, including a computer search with specific keywords, reference list search, and manual search was performed. Relevant articles were selected after three search rounds for final review based on six predefined inclusion criteria, followed by a round of critical appraisal. Eleven publications, including eight randomized controlled trials and three prospective clinical studies, were included in the review. The studies were divided into three groups based on the timing of arthrocentesis: (1) arthrocentesis as the initial treatment; (2) early arthrocentesis; and (3) late arthrocentesis. Meta-analysis was carried out to compare the efficacy of improvement in mouth opening and pain reduction in the three groups. All three groups showed improvement in mouth opening and pain reduction, with forest plots suggesting that arthrocentesis performed within 3 months of conservative treatment might produce beneficial results. We conclude that there is a knowledge gap in the current literature regarding the preferable timing to perform arthrocentesis in the management of temporomandibular disorders, and more high-quality randomized controlled trials are required to shed light on this subject.

Temporomandibular disorder severity and diagnostic groups: Their associations with sleep quality and impairments

OBJECTIVES

This study evaluated the impact of TMD severity on sleep quality and established the associations between TMD diagnostic groups/pain subtypes and sleep impairments.

METHODS

A total of 1151 patients from a tertiary Dental Hospital were screened for eligibility. Consenting subjects who met the inclusion criteria were directed to complete a general/health questionnaire, the Fonseca Anamnestic Index (FAI), Diagnostic Criteria for Temporomandibular disorders (DC/TMD) Symptom Questionnaire, and Pittsburgh Sleep Quality Index (PSQI) at their intake visit. Patients who screened positive for TMDs with the FAI were subjected to a protocolized physical examination and TMD diagnostic groups/subtypes were subsequently derived based on the DC/TMD "diagnostic tree" and algorithms. Statistical analyses were conducted using non-parametric methods and logistic regression (α = 0.05).

RESULTS

The final sample consisted of 845 subjects with TMDs and 116 TMD-free controls. The mean age of the TMD and TMD-free subjects were 33.17 ± 13.55 and 31.66 ± 9.50 years. Subjects with severe and moderate TMDs had significantly greater global PSQI scores than those with mild and no TMDs (p < 0.001). Those with pain-related, intra-articular, and combined TMDs reported significantly poorer sleep quality than those with no TMDs (p < 0.001). Moreover, subjects with myalgia and myalgia plus arthralgia presented significantly greater sleep impairments than their counterparts with intra-articular disorders (p < 0.001). Multivariate logistic regression indicated that pain-related (OR = 3.23; CI = 1.69-6.14) and intra-articular TMDs (OR = 1.91; CI = 1.15-3.16) were most related to poor sleep.

CONCLUSIONS

Sleep quality worsened with increasing TMD severity and the presence of painful and intra-articular TMDs increased the likelihood of poor sleep.

Temporomandibular Disorders: Fundamental Questions and Answers

This review aimed to present the current evidence-based answers to a questionnaire which was developed to evaluate the beliefs and knowledge of dental professionals concerning temporomandibular disorder (TMD). A literature review was conducted using the PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane, Google Scholar, and Scopus search engines from January 1980 to June 2020 corresponding to TMD diagnosis, causes, management, and consequences. A total of 50 articles were considered relevant and selected for full review. The etiology of TMD is multifactorial and complicated and involves several direct and indirect factors. Orthodontic treatment does not appear to either prevent or relieve TMD to a great degree. Nevertheless, condylar and occlusal stability reduces the risk of TMD development. As a result, an assessment of the function of masticatory system prior to beginning orthodontic therapy is fundamental. If signs and symptoms of TMD are significantly present, they should be managed before any orthodontic intervention. Moreover, psychological disorders are strongly associated with joint and facial pain. Thus, professionals who work with chronic TMD patients need to be aware of the psychological aspects of chronic pain and refer the patient for psychological evaluation when warranted. Future research elucidating a cause-effect relationship and neurobehavioral processes underlining chronic pain should be performed.

Adhesive dentistry sensory stimulus technique as a neuromechanism for the treatment of orofacial pain associated to temporomandibular disorders: Case study

Purpose

The authors intend, by presenting a case study, emphasize the neuromodulation process of orofacial pain induced by the stimulation of the sensory and motor stimulation of the trigeminal nerve, which can play an important role on pain modulation.

Materials and methods

A 25 year-old woman presenting orofacial pain was referred to the stomatology service at the Centro Hospitalar do Porto. After collecting the patient's anamnesis, the thermographic camera FLIR i7 was used to record the thermal status of the orofacial structures, before the adhesive dentistry sensory stimulus protocol, after 45 minutes, and after one week.

Results

This study suggests the relation of adhesive dentistry sensory stimulus technique in the neuromodulation of orofacial pain and its association with the temporomandibular disorders . As the tongue senses the stimulus of the resin composite placed on the palatal surface of the 1^st premolar, 2^nd premolar and 1^st molar of the maxilla, this can promote and induce an effect regarding a peripheral nerve neuromodulation resulting in a blockage of the nociceptive trigeminal pathway from temporomandibular disorders.

Conclusion

Orofacial pain is a common complaint among the patients that come to a dentistry appointment, which may have different diagnosis and treatments. A positive effect on the patient's symptomatology was confirmed clinically on subsequent dental appointments and monitored by infrared thermography.