Diagnosis and Treatment of Myogenous Temporomandibular Disorders: A Clinical Update

Exploring the causal effects of sleep characteristics on TMD-related pain: a two-sample Mendelian randomization study

OBJECTIVES

The study was to explore the causal effects of sleep characteristics on temporomandibular disorder (TMD)-related pain using Mendelian randomization (MR) analysis.

MATERIALS AND METHODS

Five sleep characteristics (short sleep, insomnia, chronotype, snoring, sleep apnea) were designated as exposure factors. Data were obtained from previous publicized genome-wide association studies and single nucleotide polymorphisms (SNPs) strongly associated with them were utilized as instrumental variables (IVs). TMD-related pain was designed as outcome variable and sourced from the FinnGens database. MR analysis was employed to explore the causal effects of the five sleep characteristics on TMD-related pain. The causal effect was analyzed using the inverse variance-weighted (IVW), weighted median, and MR-Egger methods. Subsequently, sensitivity analyses were conducted using Cochran's Q tests, funnel plots, leave-one-out analyses, and MR-Egger intercept tests.

RESULTS

A causal effect of short sleep on TMD-related pain was revealed by IVW (OR: 1.60, 95% CI: 1.06-2.41, P = 0.026). No causal relationship was identified between other sleep characteristics (insomnia, chronotype, snoring, sleep apnea) and TMD-related pain.

CONCLUSIONS

Our study suggests that short sleep may increase the risk of TMD-related pain, while there was no causal relationship between other sleep characteristics and TMD-related pain. Further studies are warranted to deepen and definitively clarify their relationship.

CLINICAL RELEVANCE

These findings reveal that the short sleep may be a risk factor of TMD-related pain and highlight the potential therapeutical effect of extending sleep time on alleviating TMD-related pain.

Temporomandibular Disorders Management-What's New? A Scoping Review

Temporomandibular disorders include various conditions that impact the masticatory system, affecting its structure, function, or physiology. Clinicians face a complex array of therapeutic options when treating this group of diseases, emphasizing the importance of evaluating the current evidence to guide decisions in patient care. The main objective of this article is to conduct a scoping review on the available treatment approaches to manage temporomandibular disorders (TMDs). An extensive search of the literature was performed on Scopus, Pubmed, Embase, and Web of Science. Systematic reviews published in the last 5 years were considered. Out of the 2183 publications identified, 109 studies were included in this review. Among them, 39 articles focused on the non-invasive approach, while 120 delved into the minimally invasive approach, and 15 explored the surgical approach. Non-invasive or conservative approaches like cognitive-behavioral therapy, physical therapy, and acupuncture offer effective pain management and functional improvements in TMDs. Emerging treatments offer promising alternatives for treating these disorders. Surgery should be reserved for severe cases, with conservative therapies used in conjunction with invasive procedures for optimal patient outcomes.

Efficacy of massage versus massage with post isometric relaxation in temporomandibular disorders: a randomized controlled trial

BACKGROUND

Temporomandibular joint disorder (TMD) is a common condition affecting the masticatory muscles and joint mobility.

OBJECTIVES

The primary objective was to compare the effects of massage therapy alone and massage therapy combined with post-isometric relaxation exercises in patients with TMD for pain and maximal mouth opening.

DESIGN

Assessor-blinded randomized controlled trial.

SETTING

Sir Ganga Ram Hospital, Chaudhry Muhammad Akram Dental Hospital, Lahore Medical and Dental Hospital.

SUBJECTS

Temporomandibular joint disorder patients.

INTERVENTION

Group A (n = 23) received conventional treatment including massage and therapeutic exercises consecutively for 2 weeks. Group B (n = 23) received post-isometric relaxation technique along with conventional treatment for consecutive 2 weeks.

MAIN MEASURES

The main outcome measures were pain and maximal mouth opening. Pain was measured using the Visual Analogue Scale (VAS) and maximal mouth opening (MMO) was measured using the TheraBite Scale.

RESULTS

Both groups demonstrated significant improvements in pain and MMO scores post-treatment. However, Group B (massage with post-isometric relaxation exercises) showed significantly better outcomes compared to Group A (massage alone). There was a statistically significant difference in post-treatment pain scores (P = 0.000) and MMO scores (P = 0.000) between the two groups.

CONCLUSION

The results suggest that massage therapy combined with post-isometric relaxation is more effective than massage therapy alone in managing pain and improving mouth opening in TMD patients. The study provides evidence supporting the use of these therapies in TMD management.

TRIAL REGISTRY NUMBER

NCT05810831. Date of registration/First submission: 15 March 2023.

Effectiveness of Laser Acupuncture for Reducing Pain and Increasing Mouth Opening Range in Individuals with Temporomandibular Disorder: A Systematic Review and Network Meta-Analysis

PURPOSE OF REVIEW

Laser acupuncture (LA) demonstrates promising results in the treatment of musculoskeletal disorders. However, its effects on temporomandibular disorder (TMD) are not yet fully understood. Thus, the aim of this systematic review and network meta-analysis was to assess the effectiveness of LA on pain intensity and maximum mouth opening range (MMO) related to TMD. A search was carried out in 11 electronic databases and references of included studies to locate randomized clinical trials (RCTs) that evaluated LA as a primary treatment for TMD. The risk of bias was assessed using the RoB 2 tool. Network meta-analysis was conducted on the MetaInsight platform, considering the pain intensity and counseling (C) as the outcome of reference. The GRADE system was used to assess the certainty of the evidence.

RECENT FINDINGS

Five studies evaluated pain intensity, four with a high risk of bias and one with a low risk. Two studies evaluated pain intensity on palpation (one with high and one with low risk of bias), and one study with high risk of bias evaluated MMO. Laser parameters were: 690-810 nm, 40-150 mW, and 7.5-112.5 J/cm2. Occlusal splint (OS) [- 2.47; CI 95% - 3.64, - 1.30] and Physiotherapy (PT) [-2.64; CI 95% - 3.94, - 1.34] reduced pain intensity compared to C. The ranking of treatments in order of effectiveness was PT > OS > LA > C > CR (craniopuncture). The certainty of the evidence was very low or low. The data do not support the indication of LA for the treatment of TMDs and new placebo-controlled RCTs must be conducted to demonstrate its effectiveness more precisely.

The effects of dry needling and face yoga on pain, depression, function, and sleep quality in patients with temporomandibular dysfunction

CONTEXT

Temporomandibular joint dysfunction (TMD) poses significant challenges due to its diverse symptoms and impact on patients' daily lives.

OBJECTIVE

This study aimed to explore the effectiveness of two innovative interventions, dry needling and face yoga, in managing TMD-related issues such as pain, depression, and sleep quality.

DESIGN AND STUDY PARTICIPANTS

Ninety patients with TMD symptoms were enrolled in a prospective randomized controlled trial. The patients were divided into three groups: dry needling, face yoga, and a control group. Various assessments, including Visual Analog Scale for pain, Beck Depression Inventory for depression, and Pittsburgh Sleep Quality Index for sleep quality, were conducted before and 6 weeks after the interventions.

RESULTS

A decrease in pain levels and a statistically significant increase in jaw joint movements (mouth opening, protrusive movement, lateral movements) were observed in the dry needling and face yoga groups after treatment (p <0.05). Additionally, improvements in sleep quality were observed (p <0.05).

CONCLUSION

Dry needling and face yoga interventions demonstrated efficacy in managing TMD symptoms, including pain relief and improved jaw movement. The findings suggest that these interventions can be valuable additions to the treatment regimen for patients suffering from TMD-related issues. However, further research is warranted to explore the long-term effects and mechanisms underlying these interventions in TMD management.

Materials and manufacturing techniques for occlusal splints: A literature review

OBJECTIVE

To review the materials and fabrications methods of occlusal splints with their advantages and shortcomings and to clarify the indications for each.

BACKGROUND

Temporomandibular joint disorders (TMDs) encompass a range of conditions affecting the masticatory system. Occlusal splints are currently recognised as a viable option for the management of TMDs when they are adopted in conjunction with additional approaches varying from conservative procedures (counselling, biofeedback, physical therapy, pharmacotherapy) to irreversible and less conservative ones (occlusal adjustments, orthodontics, arthroscopy and surgery). These splints can vary in design, function and material. The components used to fabricate the splints must withstand occlusal forces, be aesthetically pleasing, comfortable and minimally interfering with function and phonetics. Traditional methods for fabricating splints include sprinkle-on, thermoforming and lost wax techniques. However, with the advancement of CAD/CAM technology, additive (3D printing) and subtractive (milling) manufacturing methods expand the range of possibilities by introducing novel solutions for elaborating splints.

METHODS

An electronic search was conducted on PubMed using the following keywords: "occlusal splint", "guard and "materials", and "manufacturing." Thirteen in vitro publications were screened and they consisted of four clinical studies, nine reviews (three of them were systematic reviews), and five case reports.

CONCLUSION

The choice of material is crucial for the success of splint therapy. Factors such as biocompatibility, ease of fabrication, adjustability, cost and patient preference should be considered. Newer materials and techniques are emerging because of advancements in material science and manufacturing techniques. However, it should be noted that most of the evidence is based on in vitro studies with different methodologies, limiting their validity in daily practice.

Age and Gender, but Not Pain are Associated with Pressure Pain Thresholds in Patients with Temporomandibular Disorders: A Cross-Sectional Study

Purpose

This study aims to explore the association of pressure pain thresholds (PPTs) with age, gender, and pain in patients with temporomandibular disorders (TMD).

Patients and Methods

A total of 301 TMD patients (248 female and 53 male) were recruited and classified into the high and low age groups according to their median age of 26 years. Patients' demographics, pain-related variables, TMD-related variables, and PPTs of both left and right temporomandibular joints (TMJs), masseter, and temporalis were collected.

Results

Pain duration and visual analog scale of pain (VAS) showed no significant correlations with PPTs (P>0.05). Multiple linear regression analysis revealed a significant positive association of PPTs of all six sites with males (β=0.41-0.72 kg·cm-2, 95% CI (0.19-0.38, 0.74-0.99), P<0.001), as well as with the high age group [β=0.28-0.36 kg·cm-2, 95% CI (0.07-0.20, 0.47-0.53), P<0.020]. Furthermore, PPTs of the left TMJ showed a significant negative association with left pain-related TMD (PT) [β=-0.21 kg·cm-2, 95% CI (-0.38, -0.04), P=0.026], but PPTs of the remaining sites did not show a significant association with PT (P>0.05). Stratified analysis showed that PPTs in females were associated with the high age group [β=0.25-0.37 kg·cm-2, 95% CI (0.04-0.20, 0.45-0.56), P<0.020] and that PPT of the left TMJ was associated with left PT [β=-0.21 kg·cm-2, 95% CI (-0.39, -0.03), P=0.043]. The remaining PPTs did not show a significant association with PT (P>0.05). In males, PPTs did not show significant correlations with age, PT and VAS (P>0.05).

Conclusion

PPTs in the orofacial region are associated with gender and age in TMD patients. Pain duration and intensity show no significant correlations with PPTs in TMD patients. Researchers and dentists should take age and gender into account when using PPTs as auxiliary diagnostic indicators for PT.

It Is Time for a Multidisciplinary Rehabilitation Approach: A Scoping Review on Stomatognathic Diseases in Neurological Disorders

Patients affected by neurological disorders can develop stomatognathic diseases (SD) related to decreased bite force and quality of mastication, bruxism, severe clicking and other temporomandibular disorders (TMD), which deeply affect patients' swallowing, masticatory and phonation functions and, therefore, their quality of life. The diagnosis is commonly based on medical history and physical examination, paying attention to the temporomandibular joint (TMJ) range of movements, jaw sounds and mandibular lateral deviation. Diagnostic tools such as computed tomography and magnetic resonance imaging are used instead in case of equivocal findings in the anamnesis and physical evaluation. However, stomatognathic and temporomandibular functional training has not been commonly adopted in hospital settings as part of formal neurorehabilitation. This review is aimed at describing the most frequent pathophysiological patterns of SD and TMD in patients affected by neurological disorders and their rehabilitative approach, giving some clinical suggestions about their conservative treatment. We have searched and reviewed evidence published in PubMed, Google Scholar, Scopus and Cochrane Library between 2010 and 2023. After a thorough screening, we have selected ten studies referring to pathophysiological patterns of SD/TMD and the conservative rehabilitative approach in neurological disorders. Given this, the current literature is still poor and unclear about the administration of these kinds of complementary and rehabilitative approaches in neurological patients suffering from SD and/or TMD.

Botulinum Toxin and Percutaneous Needle Electrolysis for the Treatment of Chronic Masticatory Myalgia

Botulinum toxin type A (BTA) is applied in muscle hyperactivity disorders and injected into affected muscles, producing deep and persistent muscle relaxation. Several multidisciplinary groups investigated the treatment of temporomandibular disorders for several years, and there is currently some data on the beneficial effects of BTA in specific cases of chronic masticatory myalgia. Percutaneous needle electrolysis (PNE), which applies a low-intensity galvanic current to promote tissue regeneration, has been shown to be effective in reducing pain and improving masticatory function. The purpose of this study was to investigate the efficacy and safety of BTA and to assess whether its application in patients with localized masticatory myalgia can significantly reduce pain and improve function compared to a group treated with PNE. Fifty-two patients with long-term refractory masticatory myalgia were randomly assigned to two groups. The BTA group (n = 26) received a bilateral botulinum toxin injection and the PNE group (n = 26) received percutaneous electrolysis. The dose of BTA injected was 100 units distributed among the main primary masticatory muscles, and PNE was administered at 0.5 mA/3 s/3 consecutive times in a single session. Patient assessments were performed prior to treatment and one, two, and three months after treatment. The results revealed good therapeutic response in both groups. In the long term, both BTA and PNE showed high efficacy and safety in reducing pain and improving muscle function for the treatment of chronic masticatory myalgia. This improvement was sustained over a three-month period in both groups. Therefore, the use of BTA and PNE could be considered a valid and safe therapeutic alternative among the available options to treat refractory and localized masticatory myalgia when a better therapeutic response is expected as it demonstrated high efficacy.

Efficiency of occlusal splint therapy on orofacial muscle pain reduction: a systematic review

BACKGROUND

This systematic review aims to examine the existing original studies to determine the effectiveness of occlusal splints (OSs) in the management of orofacial myalgia and myofascial pain (MP) in comparison with no treatment or other interventions.

MATERIALS AND METHODS

Based on the inclusion and exclusion criteria of this systematic review, randomized controlled trials were qualified, in which the effectiveness of occlusal splint therapy in the management of muscle pain was examined in comparison with no treatment or other interventions. This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. The authors searched three databases (PubMed, CINAHL (The Cumulative Index to Nursing and Allied Health Literature) and Scopus) for English publications published between January 1, 2010, and June 1, 2022. The last database search was carried out on June 4, 2022. Data were extracted from the included studies and assessed for risk of bias using the revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Thirteen studies were identified for inclusion in this review. In total, 589 patients were diagnosed with orofacial muscle pain who underwent education and various forms of therapy including different types of OSs, light emitting diode therapy, acupuncture, low-level laser therapy, device-supported sensorimotor training, Kinesio Taping, myofunctional therapy, and physical therapy. All studies included demonstrated a high risk of bias.

CONCLUSIONS

There is insufficient evidence regarding whether OS therapy in the treatment of orofacial myalgia and MP offers an advantage over other forms of interventions or no treatment. Further reliable clinical studies in this area are needed to improve the quality of research, which should be performed with larger groups of blinded respondents and controls.

CLINICAL RELEVANCE

Due to the large-scale nature of orofacial muscle pain, it is assumed that each dental clinician will meet patients with orofacial muscle pain repeatedly in daily practice; hence, the review of the effectiveness of OSs in the management of orofacial myalgia and MP is necessary.

The reliability of using light therapy compared with LASER in pain reduction of temporomandibular disorders: a randomized controlled trial

BACKGROUND

Temporomandibular Disorders (TMD) refer to a group of symptoms where pain is the most leading cause to demand a treatment by the patient. Light therapies are of great importance at current times due to its biosafety and non-invasive quality when used for the management of TMD symptoms. This study aimed to evaluate the efficacy of red LED light with low-level LASER in treating TMD patients.

MATERIALS AND METHODS

A double-blind randomized clinical study was conducted and included 60 patients along 3 groups (20 for each group) presented with myofascial pain related to TMD. Patients were randomly divided into 3 groups. Group A were managed by applying the LED light device into the trigger points without switching the device on. A red LED light was given to group B for 5 min at the tender muscles. Group C were treated by using low-level LASER therapy for 30 s. Patients were evaluated for any improvements regarding the pain score, presence of trigger points, and trismus along 4 visits (1 week interval between each visit). Any side effects related to the 2 devices were also assessed.

RESULTS

Both group B and C patients showed a statistically significant improvement in the pain value (P < 0.05) at the 3rd and 4th visits when compared to group A. Regarding tenderness, there was a reduction in the number of trigger points in both study groups; however, the results were insignificant in group B. Statistics showed insignificant differences between group B & C patients regarding pain and number of trigger points at all visits (P > 0.05).

CONCLUSION

Both LED light and LASER therapies could effectively relieve pain associated with myogenic TMD as there were no important differences between their outcomes. However, the biosafety and lower cost of the LED light device compared to the LASER should also be considered. Trial Registration This clinical trial was prospectively registered (TCTR ID: TCTR20190507002) on 07/05/2019. URL: http://www.thaiclinicaltrials.org/show/TCTR20190507002.

Myogenous Temporomandibular Disorders: Diagnostic Concepts and Prospective Pilot Study on Extracorporeal Shockwave Therapy

The aims of this article are to discuss the current, and potential future directions, in the diagnosis of myogenous temporomandibular disorders (M-TMD), as well as to report a pilot study to investigate the feasibility and clinical outcomes of extracorporeal shockwave therapy (ESWT) in the treatment of M-TMD. Forty-one adult patients presented with M-TMD were recruited into the study and randomized into two groups: Group 1 received ESWT treatment, whereas Group 2 received placebo treatment. The variables investigated were pain, measured by a numerical rating scale (NRS) and mouth opening. Twenty-six patients (Group 1: n = 14, mean age = 45.3 (16.7) years; Group 2: n = 12, mean age = 46.8 (19.7) years) completed 1-year follow up and were included into the final analysis. In both groups, reduction in pain and increase in MO (unassisted maximum, assisted maximum, and pain-free) were seen at post-treatment 1 year. There were more reduction in pain and increase in all MO in Group 1 than Group 2, but statistical significance was not detected. No major complications were encountered in this study. Although significant differences were not seen between groups, this prospective pilot study provided preliminary evidence that ESWT is safe and potentially beneficial in the treatment of M-TMD.