Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test

Optimization of the clinical diagnostic examination algorithm of patients with a cross bite complicated by cranio-mandibular dysfunction and postural disorder

OBJECTIVE

Aim: Optimization of the clinical and diagnostic examination algorithm of patients with cross bite, aggravated by cranio-mandibular dysfunction and postural disorders.

PATIENTS AND METHODS

Materials and Methods: 22 patients aged 13-16 years with cross bite with displacement of the lower jaw were examined. The first group consisted of 15 people with a right-sided displacement of the lower jaw, the second - 7 patients with a left-sided one. The condition of the musculoskeletal system was assessed by the position of the head, shoulders, shoulder blades, back (curvature of the spine), legs, chest shape, and abdomen. To determine the state of stability of the body in space, posturological and kinesiological tests were performed. The location of TMJ elements was evaluated on orthopantomograms. Statistical processing of the material was carried out with the help of the "Excel" license package.

RESULTS

Results: 63.64% of patients with a cross bite have disorders of the musculoskeletal system: scoliotic posture - 40.91% and scoliosis - 22.73%. TMJ dysfunction was detected in all examined patients. It was established that the anatomical and topographic features of the joint elements depend on the side of the lower jaw displacement.

CONCLUSION

Conclusions: The functional imbalance of all structural elements of the musculoskeletal system and the cranio-mandibular complex determined during the research proved the need to optimize the clinical-diagnostic algorithm: consultation of a traumatologist-orthopedic doctor, X-ray examination of TMJ, conducting posturological tests.

Somatosensory tinnitus and temporomandibular disorders: A common association

BACKGROUND

Although the association between tinnitus and temporo-mandibular disorders (TMD) has been frequently reported, their rate of association in the literature shows a great variability.

OBJECTIVE

We aimed to investigate the prevalence of TMD in patients with somatosensory tinnitus and, vice versa, the occurrence of somatosensory tinnitus in patients with TMD.

METHODS

The study included patients with somatosensory tinnitus (audiological group) and patients with TMD (stomatological group), evaluated at the audiologic and stomatologic clinics of the Policlinic Hospital of Milan, Italy. Common causes of tinnitus, such as hearing and neurological disorders, were excluded. A cervicogenic somatic tinnitus was also ruled out. Different TMD symptoms, including joint noise and joint pain, were considered. The collected data were analysed using descriptive statistical methods, and the Pearson's Chi-squared test was performed to study the prevalence of the different symptoms by clinical groups.

RESULTS

Audiological group included 47 patients with somatosensory tinnitus. Overall, TMD was diagnosed in 46 patients (97.8%), including TMJ noise in 37 (78.7%), clenching in 41 (87.2%) and pain in 7 (14.8%) patients. Stomatological group included 50 patients with TMD, including joint noise in 32 (64.0%), clenching in 28 (56.0%) and TMJ pain in 42 (84.0%) patients. A somatosensory tinnitus was diagnosed in 12 (24.0%) patients.

CONCLUSION

Our study showed a high prevalence of TMD in patients with tinnitus, as well as a not uncommon occurrence of tinnitus in patients presenting with TMD. The distribution of TMD symptoms, such as joint noise, and joint pain was different between the two groups.

Manual Therapy Applied to the Cervial Joint Reduces Pain and Improves Jaw Function in Individuals with Temporomandibular Disorders: A Systematic Review on Manual Therapy for Orofacial Disorders

AIMS

To examine the effect of manual therapy applied to the cervical joint for reducing pain and improving mouth opening and jaw function in people with TMDs.

METHODS

A systematic review of randomized controlled trials was performed. Participants were adults diagnosed with TMDs. The experimental intervention was manual therapy applied to the cervical joint compared to no intervention/placebo. Outcome data relating to orofacial pain intensity, pressure pain threshold (PPT), maximum mouth opening, and jaw function were extracted and combined in meta-analyses.

RESULTS

The review included five trials involving 213 participants, of which 90% were women. Manual therapy applied to the cervical joint decreased orofacial pain (mean difference: -1.8 cm; 95% CI: -2.8 to -0.9) and improved PPT (mean difference: 0.64 kg/cm2; 95% CI: 0.02 to 1.26) and jaw function (standardized mean difference: 0.65; 95% CI: 0.3 to 1.0).

CONCLUSION

Manual therapy applied to the cervical joint had short-term benefits for reducing pain intensity and improving jaw function in women with TMDs. Further studies are needed to improve the quality of the evidence and to investigate the maintenance of benefits beyond the intervention period.

Temporomandibular Joint Dysfunctions: A Systematic Review of Treatment Approaches

Temporomandibular disorders (TMDs) encompass a diverse array of conditions affecting both the structure and function of the jaw. The aetiology of TMDs is multifactorial and may arise from muscular and joint disorders, degenerative processes, or a combination of various symptoms. The objective of this review was to analyse the physiotherapy treatment techniques used for the management of temporomandibular disorders. This review also aimed to compare the effectiveness of the differenttreatment methods used and identify the dysfunctions for which physiotherapy interventions are applied as the main treatment. A systematic literature review was conducted using the PubMed, ScienceDirect, Dialnet, and PEDro databases. After applying the inclusion criteria, 15 out of 656 articles were included. The application of different physiotherapy techniques, both alone and in combination, is effective in controlling the primary symptoms of TMD in patients. These symptoms include pain, functionality, and quality of life. The use of physiotherapy as a conservative intervention method for TMDs is supported by sufficient scientific evidence. The combination of different therapies within physiotherapy achieves the best results in treatment. Therapeutic exercise protocols, in combination with manual therapy techniques, are the most commonly utilized method for addressing TMDs and thus provide the best results according to the analysed studies.

Effectiveness of manual therapy and cervical spine stretching exercises on pain and disability in myofascial temporomandibular disorders accompanied by headaches: a single-center cohort study

BACKGROUND

Previous studies have demonstrated a relationship between headaches and temporomandibular disorders (TMDs). Moreover, recent studies have shown functional, anatomical, and neurological associations between the temporomandibular joint (TMJ) and upper cervical spine. This study aimed to investigate the effectiveness of manual therapy and cervical spine stretching exercises for pain and disability in patients with myofascial TMDs accompanied by headaches.

METHODS

Thirty-four patients recruited from Gyeryong Hospital with headaches and diagnosed with TMDs were randomly assigned to the experimental (n = 17) and control (n = 17) groups. Headache impact was assessed using the Korean Headache Impact Test-6. Masseter myofascial pain was measured using the visual analog scale, and TMJ pressure pain threshold levels were evaluated using an algometer. Neck pain intensity was assessed using the numerical rating scale. Once per week for 10 weeks, the experimental group received cervical spine-focused manual therapy and stretching exercises alongside conservative physical therapy, and the control group received conservative physical therapy alone. Patients were evaluated at baseline and 5 and 10 weeks post-intervention.

RESULTS

After the intervention, the experimental group exhibited significant reductions in the cervical kyphotic angle, Korean Headache Impact Assessment score, neck pain intensity, TMJ pain pressure threshold, Neck Disability Index score, and Jaw Functional Limitation Scale level compared with the control group (p < 0.01).

CONCLUSION

Manual therapy and stretching exercises could help resolve TMDs accompanied by headaches through biomechanical changes in the cervical spine. These findings may guide protocols and clinical trials involving manual therapy that align morphological structures.

Relationship between self-reported pain, pain threshold, pain catastrophization and quality of life in patients with TMD

Background

The aim of this study was to verify if there is a relationship between self-reported pain, PPT (pressure pain threshold) of the masseter, temporal and sternocleidomastoid muscles, pain catastrophizing and quality of life in patients with TMD (temporomandibular disorder) of muscular origin.

Material and Methods

Ninety-seven patients with muscular TMD (TMD group) and 97 asymptomatic (control group) were included in the study. The evaluation methods used were: 1) Self-reported pain was assessed using the Visual Analogue Scale (VAS) for questions 7, 8 and 9 of the RDC/TMD Axis I questionnaire; 2) The PPT assessment was performed using a digital algometer on the masseter, temporal, and sternocleidomastoid muscles (both sides); 3) Pain catastrophizing was assessed using the PCS (Pain Catastrophizing Scale); and 4) Oral health-related quality of life was assessed using the OHIP-14 (Oral Healthy Impact Profile-14). Data were submitted to Spearman correlation and logistic regression (p<0.05).

Results

There were significant positive correlations between self-reported pain (VAS-Q7, VAS-Q8 and VAS-Q9), pain catastrophizing (PCS-Helplessness, PCS-Magnification, PCS-Rumination and PCS-Total) and quality of life (OHIP-14) (p<0.05). There was a significant negative correlation of self-reported pain (VAS-Q8) with PPT of the temporal (left) and sternocleidomastoid (both sides) (p<0.05). The rumination and magnification domains increased the chance of high self-reported pain in all situations (VAS-Q7, VAS-Q8 and VAS-Q9) (p<0.05). The helplessness domain only increased the chance of high self-reported pain for VAS-Q8 (p<0.05). The presence of TMD of muscular origin, high self-reported pain (VAS-Q7) or pain catastrophizing increased the chance of a low quality of life in relation to the control group (p<0.05). In addition, the reduction in sternocleidomastoid PPT increased the chance of poor quality of life (p<0.05). Key words:Myofascial pain syndromes, pain catastrophizing, myalgia, quality of life, surveys and questionnaires, temporomandibular joint disorders.

Validity of the Isometric Contraction Test of the Masticatory Muscles for Diagnosis of Muscular Temporomandibular Disorders

In recent years, the Diagnostic Criteria for Temporomandibular Pain Disorders (DC/TMD) has been questioned, mainly because of the dependence on the muscular pressure needed to be applied during the clinical examination. Therefore, it is necessary to establish improvements in diagnostic strategies for DC/TMD of axis I. The aim of this study was to determine the validity of the Isometric Contraction Test of the masticatory muscles (ICTest) to diagnose DC/TMD of axis I. Forty (n = 40) patients with muscular TMD (myalgia in any of its subtypes), as well as forty age and sex matched controls, participated. They were diagnosed according to DC/TMD of axis I and performed the ICTest in a single session. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and positive (LR+) and negative likelihood ratios (LR−) of the ICTest compared with the DC/TMD of axis I were calculated. The ICTest showed a specificity of 95% for the diagnosis of myalgia, and between 94.9% and 96.8% for all subtypes in relation to the DC/TMD of axis I. For sensitivity, lower values were obtained, that is, 90.0% for myalgia, and losing sensitivity depending on the type of myalgia. The LR+ was over 10 for all diagnoses, with the exception of myofascial pain with referral, which was lower. When addressing the LR−, the myofascial diagnosis was the only one below 0.2. According to the results, the ICTest could be considered a valid procedure to diagnose subjects with muscular TMD in a clinical setting.

Conservative management of pediatric temporomandibular disc displacement presenting as juvenile idiopathic arthritis: a case report

There is limited research regarding management of temporomandibular disorders (TMD) in adolescents with imaging signs of juvenile idiopathic arthritis (JIA). An 11-year-old girl presented to a hospital-based chiropractor for evaluation of a 1.5-year history of unilateral temporomandibular joint (TMJ) pain and trismus. Previously, pediatric rheumatologists diagnosed JIA after contrast-enhanced magnetic resonance imaging revealed edema, effusion, and bilateral anterior disc displacement, and recommended methotrexate, corticosteroid injection, and arthrocentesis. The chiropractor questioned the JIA diagnosis, instead relating symptoms to a mechanical TMD/disc origin. Manual therapy, TMJ exercises, and acupuncture improved TMJ pain and opening. Invasive medical JIA interventions were avoided without long-term recurrence, further questioning the preceding JIA diagnosis. The success of this case suggests that stepped care, beginning with conservative treatment, has value for adolescents with TMD suspect for JIA. Integration of chiropractors and acupuncturists into healthcare institutions may facilitate this care model by affording nonpharmacologic interventions earlier in patient care.

A home-based exercise program for temporomandibular joint osteoarthritis: pain, functionality, and joint structure

Objectives

Osteoarthritis (OA) is the most prevalent and disabling joint disease in the world. Temporomandibular joint (TMJ) exercise is a widely used treatment and could be a beneficial and long-term tool for treating TMJ OA. The present study aims to evaluate the effects of therapeutic exercise in the conservative treatment of TMJ OA.

Materials and Methods

A single-group experimental pre-post test was performed. We included patients who met the diagnostic criteria for TMJ OA. Outcome variables were pain intensity (visual analogue scale), functionality (Helkimo index), and structural changes (ultrasound). Follow-up periods were at months 1, 3, and 6. The intervention included a home-based program with thermotherapy, manual therapy, and therapeutic exercise during the entire follow-up period.

Results

We included 15 patients and 26 joints, all women with a median age of 57 years (range, 49-62 years). Median change in pain intensity on joint palpation, mouth opening, and at rest at the first month was 47.5 mm, 51 mm, and 60 mm, respectively, and 48 mm, 49.5 mm, and 42.5 mm, at six months (P=0.001). The Helkimo index showed significant improvement in medians from baseline severe dysfunction (17 points) to minimal dysfunction at three and six months (2 points) (P=0.001). Ultrasound showed improved disc position.

Conclusion

This study demonstrated significant improvements in pain, function, and joint disc position and represents a valuable tool for the long-term treatment of patients with TMJ OA.

Potential adjunct therapies for the management of temporomandibular disorders: An evidence-based review

OBJECTIVE

The aim was to review the role of adjuvant therapies that may potentially contribute toward the management of temporomandibular disorders (TMD).

METHODS

The addressed focused question was, "Are there any adjuvant therapies that may contribute toward the management of TMD?". Indexed databases were searched up to June 2021. The eligibility criteria were the following: (a) original clinical studies and (b) randomized controlled clinical trials (RCTs).

RESULTS

Adjuvant therapies were comprised of acupuncture, manual therapy, jaw exercises, dietary modifications, botulinum toxin therapy, and photobiomodulation. Short-term follow-up results from each of these RCTs showed beneficial effects in terms of pain reduction and improvements in jaw movement among patients with TMD. There are no long-term follow-up results in this regard.

CONCLUSION

The most effective adjunct treatment for managing TMD remains unknown, primarily due to a lack of sufficient scientific evidence.

Manual therapy for temporomandibular disorder in older adults: an integrative literature review

ABSTRACT Purpose: to describe the manual therapy techniques used to treat the temporomandibular disorder in older adults. Methods: an integrative literature review assessing scientific publications indexed in six databases: MEDLINE/PubMed, Web of Science, CINAHL, Scopus, LILACS, and PEDro. Only intervention studies were included, with no restriction of date or language. The articles included in the review were assessed with the Critical Appraisal Skills Programme. Results: after consulting the databases, 88 articles were found, six of which were considered eligible. No study was found exclusively approaching older adults. According to the analysis of the risk of bias, two articles were classified as low-risk, two as intermediate, and two as high-risk. The manual therapy techniques were intra- and extraoral massage, temporomandibular joint and cervical spine mobilization, myofascial release, trigger-point finger pressure, and deep transverse massage. Conclusion: the studies observed improved mandibular movements and masticatory function, eased pain, and reduced anxiety.

Terapia manual na disfunção temporomandibular em pessoas idosas: uma revisão integrativa da literatura

ABSTRACT Purpose: to describe the manual therapy techniques used to treat the temporomandibular disorder in older adults. Methods: an integrative literature review assessing scientific publications indexed in six databases: MEDLINE/PubMed, Web of Science, CINAHL, Scopus, LILACS, and PEDro. Only intervention studies were included, with no restriction of date or language. The articles included in the review were assessed with the Critical Appraisal Skills Programme. Results: after consulting the databases, 88 articles were found, six of which were considered eligible. No study was found exclusively approaching older adults. According to the analysis of the risk of bias, two articles were classified as low-risk, two as intermediate, and two as high-risk. The manual therapy techniques were intra- and extraoral massage, temporomandibular joint and cervical spine mobilization, myofascial release, trigger-point finger pressure, and deep transverse massage. Conclusion: the studies observed improved mandibular movements and masticatory function, eased pain, and reduced anxiety.

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.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT.

DESIGN

Systematic review and meta-analysis (MA).

METHODS

A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies' objectives. The qualitative analysis was based on classifying the results into levels of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Regarding cervical MT, MA included three studies and showed statistically significant differences in pain intensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity reduction and pain-free maximal mouth opening, with a large clinical effect.

CONCLUSIONS

Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain-free MMO over cervical intervention alone in TMD and headache, with low evidence.

Occurrence and severity of neck disability in individuals with different types of temporomandibular disorder

BACKGROUND

Healthcare professionals need to know the degree of disability and severity of their patients to determine actions and therapy needed to minimize potential harm, improve their patient condition, and maximize clinical outcomes.

OBJECTIVES

To evaluate the occurrence and severity of neck disability in individuals with muscular, joint, and mixed temporomandibular disorder (TMD).

MATERIALS AND METHODS

Cross-sectional study with individuals divided into four groups: muscular TMD (n=20), joint TMD (n=20), mixed TMD (n=20) and control (n=20). For diagnosis and classification of TMD, it was used the Research Diagnostic Criteria (RDC) and to assess the severity of neck dysfunction the Neck Disability Index (NDI).

RESULTS

Moderate neck disability was frequent in all individuals with TMD; high scores of neck disability index were evidenced in the mixed and joint TMD groups; there was a moderate positive correlation between the severity of neck disability and TMD severity (r=0.7; CI=0.32-0.78; p<0.03).

CONCLUSION

The gravity of neck disability and the severity of TMD are directly proportional in the group of individuals with mixed TMD.

Instrumental validity and intra/inter-rater reliability of a novel low-cost digital pressure algometer

Background

Pain assessment is a key measure that accompanies treatments in a wide range of clinical settings. A low-cost valid and reliable pressure algometer would allow objective assessment of pressure pain to assist a variety of health professionals. However, the pressure algometer is often expensive, which limits its daily use in both clinical and research settings.

Objectives

This study aimed to assess the instrumental validity, and the intra- and inter-rater reliability of an inexpensive digital adapted pressure algometer.

Methods

A single rater applied 60 random compressions on a force platform. The pressure pain thresholds of 20 volunteers were collected twice (3 days apart) by two raters. The main outcome measurements were as follows: the maximal peak force (in kPa) and the pressure pain threshold (adapted pressure algometer vs. force platform). Cronbach’s α test was used to assess internal consistency. The standard error of measurement provided estimates of measurement error, and the measurement bias was estimated with the Bland–Altman method, with lower and upper limits of agreement.

Results

No differences were observed when comparing the compression results (P = 0.51). The validity and internal intra-rater consistencies ranged from 0.84 to 0.99, and the standard error of measurement from 0.005 to 0.04 kPa. Very strong (r = 0.73–0.74) to near-perfect (r = 0.99) correlations were found, with a low risk of bias for all measurements. The results demonstrated the validity and intra-rater reliability of the digitally adapted pressure algometer. Inter-rater reliability results were moderate (r = 0.55–0.60; Cronbach’s α = 0.71–0.75).

Conclusion

The adapted pressure algometer provide valid and reliable measurements of pressure pain threshold. The results support more widespread use of the pressure pain threshold method among clinicians.

Effectiveness of Cervical Spine High-Velocity, Low-Amplitude Thrust Added to Behavioral Education, Soft Tissue Mobilization, and Exercise for People With Temporomandibular Disorder With Myalgia: A Randomized Clinical Trial

OBJECTIVE

To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia.

DESIGN

Randomized clinical trial.

METHODS

Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction.

RESULTS

There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS (d = 0.60) and TSK-TMD (d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25).

CONCLUSION

Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175.

Relationship between specific temporomandibular disorders and impaired upper neck performance

Upper neck impairments are more prevalent in patients with temporomandibular disorders (TMDs) but the differences between specific types of TMDs are unclear. This study evaluated the distribution of such impairments among different forms of TMD. In total, 116 participants (86 women and 30 men, age range 21-75 yr) were investigated. Forty-two individuals had no TMDs and were assigned to the control group. The remaining 74 patients were assigned to one of three groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) findings: pain-related (n = 37); intra-articular (n = 17); or mixed (combined pain-related and intra-articular) (n = 20). Analyses of impairments included between-group comparisons of key parameters of upper neck performance (active/passive mobility and muscular capabilities) and pain (subjective neck disability and pain sensitivity). Patients in the pain-related and mixed TMD groups were found to have decreased upper neck mobility in the cervical flexion-rotation test compared with patients in intra-articular and control groups, as well as poorer capabilities of the deep neck flexor muscles in the cranio-cervical flexion test compared to the control group. It was concluded that patients with pain-related TMD diagnoses are more likely to experience significant upper-neck hypomobility and poor muscular capabilities than patients with intra-articular diagnoses of TMD.

Treatment of Temporomandibular Joint Disorders by Ultrashort Wave and Extracorporeal Shock Wave: A Comparative Study

Background

This study was carried out to compare the therapeutic efficacy of extracorporeal shock wave (ESW) and ultrashort wave (UW) for temporomandibular joint disorder (TMD).

Material/Methods

A total of 80 patients with myofascial pain and TMD were enrolled in this study. The subjects were randomized to receive ESW or UW treatments. Patients in the ESW group received 1 ESW treatment for 4 weeks and patients in the US group were given US treatment once a day for 5 days per week for 4 weeks. The pain was measured using visual analog scale (VAS) and mouth opening was determined as pain-free maximum mouth opening (MMO) before and 4 weeks after the treatments. Other parameters assessed included functional indexes of temporomandibular joint such as mandibular movement (MM), joint noise (JN), joint press (JP), and disability index (DI).

Results

After therapy, VAS, MMO, MM, JN, JP, and DI in ESW group, and VAS in UW group were significantly improved (P<0.05) as compared to before therapy. VAS, MMO, and the functional indexes of temporomandibular joint in the ESW group were significantly better than those in the UW group (1.79 vs. 2.00, 3.23 vs. 2.03, 1.79 vs. 2.41, 1.45 vs. 2.27, 1.55 vs. 2.59, and 3.30 vs. 4.79, respectively. P<0.05).

Conclusions

ESW significantly reduces pain and improves the functional indexes of temporomandibular joint and mouth opening limit for TMD patients as compared with UW therapy.

What is the minimal important difference of pain intensity, mandibular function, and headache impact in patients with temporomandibular disorders? Clinical significance analysis of a randomized controlled trial

BACKGROUND

There are insufficient studies providing Minimal Clinically Important Difference (MCID) for outcomes related to temporomandibular disorders (TMD).

OBJECTIVES

(1) To provide the MCID of outcomes related to TMD using the Global Rating of Change Scale (GRCS) as an anchor. (2) To verify which outcomes can predict a moderate or large response to the treatment.

STUDY DESIGN

Secondary analysis of a randomized controlled trial in subjects with TMD.

METHODS

Sixty-one women with TMD were divided into intervention and control groups. Visual Analogue Scale (VAS), Headache Impact Test (HIT-6), pressure pain thresholds (PPTs) of masticatory muscles, Mandibular Function Impairment Questionnaire (MFIQ), and Craniocervical Flexion Test (CCFT) were collected at baseline and 5-weeks follow-up.

RESULTS

Participants were divided based on their response to the treatment, according to the GRCS. MCID values were provided for subjects that moderately or largely improved to the treatment. MCID was between 0 and 1.90 for orofacial pain, around 2 points for the MFIQ, between 3 and 6.26 points for the HIT-6, around 0.2 kg/cm2 for the PPTs on masticatory muscles, around 2.5 mm for MMO and between 60 and 68 points for CCFT. Orofacial pain and HIT-6 were the most discriminative variables at determining whether patients would largely/moderately improve or would not improve after treatment.

CONCLUSIONS

The values of MCID could be used as guidance for both clinical practice and research. Pain intensity and headache impact were the most predictive outcomes for improvement of the general health status of women with TMD.

Analysis of Masticatory Muscle Activity Based on Presence of Temporomandibular Joint Disorders

Background

This study was conducted to analyze the activity of masticatory muscles depending on the presence of temporomandibular joint disorders (TMD) when foods of various hardness are masticated.

Material/Methods

We enrolled 20 subjects (13 men and 7 women) who met our selection criteria, and they were divided into 3 groups (the Disorder Group, the Malalignment Group, and the Control Group) based on surveys and screening inspection. The average of reference voluntary contraction (RVC) was used to measure masticatory muscle activity. Using surface electromyography (SEMG) for each group during masticatory activity, the activities of the masseter muscle and temporalis muscle were measured based on the hardness of 3 different foods (soft, sticky, and hard).

Results

Characteristics of these 3 groups prior to the experiment were identical, and subsequent findings were as follows: First, when masticating sticky food, the Disorder Group and Malalignment Group showed significant differences from the Control Group in activities of the masseter muscle and temporalis muscle (p<0.05). Second, when masticating hard food, the Malalignment Group and Control Group showed significant differences from the Disorder Group in the masseter muscle and temporalis muscle activities (p<0.05). Based on these findings, the study showed that malalignment affects movement of the temporomandibular joint during mastication of sticky food, and the temporomandibular joint movement was affected by the presence of pain during mastication of hard food.

Conclusions

Our results provide basic data useful in the diagnosis of temporomandibular joint disorder, as well as guiding future studies on this topic.

Treatment of Somatosensory Tinnitus: A Randomized Controlled Trial Studying the Effect of Orofacial Treatment as Part of a Multidisciplinary Program

Background: Tinnitus, or ringing in the ears, is a perception of sound in the absence of overt acoustic stimulation. In some cases, tinnitus can be influenced by temporomandibular somatosensory input, then called temporomandibular somatosensory tinnitus (TST). It is, however, not entirely known if orofacial treatment can decrease tinnitus severity. The purpose of this study was to evaluate the effect of orofacial treatment on tinnitus complaints in patients with TST. Methods: Adult patients with TST were included, and all patients received information and advice about tinnitus and conservative orofacial treatment consisting of physical therapy, and, in case of grinding, occlusal splints were applied. Included patients were randomly assigned to an early start group and a delayed start group according to our delayed treatment design. Results: In total, 40 patients were included in each group. The treatment effect on tinnitus severity was investigated using the tinnitus questionnaire (TQ) and Tinnitus Functional Index (TFI). Regarding the TQ score, no clinically relevant reductions were observed, and no significant differences in the decrease were observed between the early start group and delayed start group. Contrarily, a significantly higher percentage of patients showed a decrease in the TQ degree in the early start group compared to the delayed start group (30.0% versus 2.8%, p = 0.006). The TFI score did show a significantly greater and clinically relevant reduction in the early start group compared to the delayed start group (p = 0.042). Conclusion: A multidisciplinary non-invasive orofacial treatment was able to reduce tinnitus severity in patients with temporomandibular related somatosensory tinnitus.

Predictors of pain reduction following manual therapy in patients with temporomandibular disorders: a protocol for a prospective observational study

INTRODUCTION

Temporomandibular disorders (TMDs) are principally characterised by pain in the craniomandibular area and probable limitations of jaw opening. Manual therapy, like other recommended conservative treatments included in clinical guidelines, is commonly used to treat patients with TMD to reduce pain and improve function. However, outcomes may be variable. The aim of this study is to identify predictors associated with pain reduction in patients with TMD following manual therapy by analysing a combination of patient-reported outcome measures and clinical tests. Such knowledge will support a more personalised management approach by facilitating clinical decision-making.

METHODS/ANALYSIS

An observational prospective design will recruit a cohort of 100 adults with a diagnosis of TMD (according to Axis I of the Diagnostic Criteria for TMD) at a Dental Hospital in Italy. Patients will be treated with four weekly sessions of manual therapy applied to craniomandibular structures. An array of predictors has been chosen based on previous research on prognostic factors for TMD and altered pain modulation in musculoskeletal disorders. Candidate predictors including demographic variables, general health variables, psychosocial features, TMD characteristics and clinical tests of the temporomandibular joint and masticatory muscles will be collected at baseline. Definition of good outcome is a clinically significant reduction of pain intensity over the last week (≥30% reduction Visual Analogue Scale) immediately following the four week intervention. Exploratory factor analysis will be applied to analyse factor loading of candidate predictors for good outcome at four weeks. Subsequently, a logistic multivariable regression model will be performed to calculate low and high risk of good outcome.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the 'Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico' and University of Birmingham Ethics Committee. The results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT03990662; Pre-results.

[Somatic dysfunctions of the cervical spine and fixed orthodontic treatment: a 145 subjects-cross sectional study]

Objectives : The aim of this blind cross-sectional study is to evaluate the influence of a fixed orthodontic appliance on the cervical spine.

MATERIALS AND METHODS

 Number and severity of somatic dysfunctions (i.e. alteration of the function of an element constituting the somatic system or SD) of the cervical spine have been searched on patients sorted out in three groups: subjects without orthodontic treatment (group 1), subjects wearing fixed orthodontic appliance (group 2) and subjects in a retention period after removal of the fixed orthodontic appliance (group 3) and were compared thanks to khi² test.

RESULTS

 A total of 145 patients from 6 to 17 years old was included. There are more SD in the second group (p = 0.006) than in the first group. There is no difference between the 1^st and the 3^rd group (p = 0.2), between the 2^nd and the 3^rd group (p = 0.4) and between the three groups (p = 0.6) concerning the severity of SD.

CONCLUSION

 Cervical disorders should not be attributed to long-term multi-attachment treatment since once the active orthodontic treatment is finished, the SD are not significantly increased compared to the control group. These results may encourage to make a study to evaluate benefits of cervical osteopathic follow-up for patients at risk after the setting of the fixed appliance.

Efficacy of mandibular manipulation technique for temporomandibular disorders patients with mouth opening limitation: a randomized controlled trial for comparison with improved multimodal therapy

PURPOSE

Manual therapy has been used for the treatment of patients with temporomandibular disorders (TMD) with mouth-opening limitations. However, the curative effect of manipulation differs among researchers, and its necessity remains controversial. The purpose of this study was to confirm the efficacy of manipulation using a randomized controlled trial (RCT).

METHODS

A total of 61 TMD patients who had mouth-opening limitation (upper and lower middle incisor distance ≤35mm) were selected. They were divided into two treatment groups: conventional treatment (n=30) and conventional treatment plus manipulation (n=31). The conventional treatment included two types of self-exercise: cognitive behavioral therapy for bruxism and education. Mouth-opening limitation, orofacial pain, and temporomandibular joint (TMJ) sounds were recorded from baseline to 18 weeks after baseline. These parameters were statistically compared between the two treatment groups by using analysis of variance (ANOVA) and Scheffe's test to assess mouth opening distance and pain; TMJ sounds were compared using Mann-Whitney U test.

RESULTS

No statistical difference was observed between the two treatment groups except for mouth-opening limitation after treatment at the first visit. Subgroup analyses, stratified according to the pathological type of TMD, indicated a similar trend.

CONCLUSIONS

The efficacy of manipulation seems to be limited, in contrast to our expectations, and improved execution of therapeutic exercises has a similar effect to that of manipulation during long-term observation. The advantage of manipulation was observed only during the first treatment session. The RCT was registered in the University Hospital Medical Information Network in Japan (UMIN-CTR: 000010437).

Orofacial pain of cervical origin: A case report

BACKGROUND

The etiopathogenesis of orofacial pain remains complex and a number of pain referral patterns for this region have been reported in the literature. The purpose of this report is to describe the assessment and successful clinical management of orofacial pain possibly attributable to cervical origin.

CASE DESCRIPTION

A 55-year-old male teacher with a 3-year history of pain in the right lower jaw, radiating to the ear, consulted our institute for assessment and management. The patient was unsuccessfully treated for dental pain and trigeminal neuralgia. The patient's functioning was grossly limited and the patient was unable to sleep because of severe pain. Current and previous medical and physical examinations revealed no infection, malignancies, or sinusitis. Palpation revealed no temporomandibular disorder, tenderness or myofascial trigger points. Examination of the cervical range of motion showed a reduction in rotation to the right side. The patient was treated for upper cervical joint dysfunction involving mobilization of the first three cervical vertebrae and motor control exercises. The patient had an almost complete resolution of symptoms and reported significant improvement in the Patient Specific Functional Scale (PSFS) and the Global Rating of Change (GRC) scale.

CONCLUSION

This case study demonstrates the importance of considering, assessing and treating the cervical spine as a possible source of orofacial pain, and the positive role of cervical mobilization on these disorders.

Effect of joint mobilization techniques for primary total knee arthroplasty: Study protocol for a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has become the most preferred procedure by patients for the relief of pain caused by knee osteoarthritis. TKA patients aim a speedy recovery after the surgery. Joint mobilization techniques for rehabilitation have been widely used to relieve pain and improve joint mobility. However, relevant randomized controlled trials showing the curative effect of these techniques remain lacking to date. Accordingly, this study aims to investigate whether joint mobilization techniques are valid for primary TKA.

METHODS/DESIGN

We will manage a single-blind, prospective, randomized, controlled trial of 120 patients with unilateral TKA. Patients will be randomized into an intervention group, a physical modality therapy group, and a usual care group. The intervention group will undergo joint mobilization manipulation treatment once a day and regular training twice a day for a month. The physical modality therapy group will undergo physical therapy once a day and regular training twice a day for a month. The usual care group will perform regular training twice a day for a month. Primary outcome measures will be based on the visual analog scale, the knee joint Hospital for Special Surgery score, range of motion, surrounded degree, and adverse effect. Secondary indicators will include manual muscle testing, 36-Item Short Form Health Survey, Berg Balance Scale function evaluation, Pittsburgh Sleep Quality Index, proprioception, and muscle morphology. We will direct intention-to-treat analysis if a subject withdraws from the trial.

DISCUSSION

The important features of this trial for joint mobilization techniques in primary TKA are randomization procedures, single-blind, large sample size, and standardized protocol. This study aims to investigate whether joint mobilization techniques are effective for early TKA patients. The result of this study may serve as a guide for TKA patients, medical personnel, and healthcare decision makers.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/showproj.aspx?proj=15262 (Identifier:ChiCTR-IOR-16009192), Registered 11 September 2016. We also could provide the correct URL of the online registry in the WHO Trial Registration. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-IOR-16009192.

The effects of regular exercise on capsaicin-induced pulpal pain and pain-induced changes in passive avoidance learning and memory in rats

Background

Pulpal pain is one of the most common and severe orofacial pain conditions with considerable adverse effects on physiological processes including learning and memory. Regular exercise is known to be effective on cognitive function as well as pain processing in the central nervous system. Here, the possible effects of regular exercise on pulpal pain response as well as pain-induced changes in learning and memory efficiency in rats were investigated.

Methods

Twenty-four male Wistar rats were randomly assigned to the control, capsaicin, exercise, and exercise plus capsaicin groups. Rats in exercise groups were forced to run on a treadmill with a moderate exercise protocol for 4 weeks. Capsaicin was used to induce dental pulp pain. Passive avoidance learning and memory performance was assessed by using a shuttle box apparatus.

Results

According to the results, regular exercise could decrease the time course of capsaicin-induced pulpal pain (P < 0.001). Moreover, in capsaicin-treated rats, passive avoidance acquisition was impaired as compared to the control (P < 0.05) and exercise (P < 0.001) groups. Additionally, regular exercise before capsaicin injection could attenuate capsaicin-induced memory impairments (P < 0.05).

Conclusions

Taken together, the present data showed that regular exercise has inhibitory effects on capsaicin-induced pulpal pain as well as pain-induced cognitive dysfunction in rats.