These results indicate that CFA causes dynamic morphological changes in the condyle and that our experimental approach will provide new insights into the subacute inflammatory processes in the TMJ.
The findings provide multimeasure and multimethod support for genetic moderation of a maladaptive coping and pain process, which has been previously characterized in a sample of postoperative shoulder pain patients. Further, the findings advance our understanding of the role of COMT in FM, suggesting that genetic variation in the val158met polymorphism may affect FM pain through pathways of pain-related cognition.
The findings of this study suggest that in cases where additional condylar surgery was undertaken, over two thirds of the joints (68.8%) showed evidence of remodeling on postoperative OPGs. The interpositional dermis-fat graft failed to prevent significant condylar changes (CMS = 2) in about one third of patients who underwent TMJ discectomy, with the youngest (mean, 30.2 years) and the oldest (mean, 55.6 years) patients being most susceptible to condylar resorption.
Patients older than 21 and those who are female should be informed before removal of all 4 third molars that their oral function, lifestyle, and pain recovery will be prolonged compared with those who are younger and male.
Claims have been made that certain diagnostic devices should be routinely used to differentiate between jaw dysfunction and normal variation and between various pathologic conditions of the temporomandibular joint. The claims that jaw-tracking devices have diagnostic value for detecting TMD are not well supported by the scientific evidence. The clinical usefulness of electromyography devices is limited because of technical, methodologic, and data interpretation problems, as well as significant overlap between asymptomatic and symptomatic groups. Claims for the use of sonography and vibratography machines to discriminate between various intracapsular TMJ conditions have not been substantiated by well-designed research. Until acceptable levels of technical and diagnostic validity have been clearly established, these diagnostic devices cannot be relied on as aids in differential diagnosis or in clinical decision making in the TMD field.
It is the aim of this paper to give a few examples of dogmas related to prosthodontics and oral implants and to discuss the controversial role of occlusion in the aetiology of temporomandibular disorders. New knowledge is developing at a rapidly increasing rate in dentistry, as in other areas of society. Our lecturers at university taught us many useful things. But, as time goes by, what is still relevant? Some methods are so well established that they deserve to be called dogmas. It is implied that a dogma is not supported by strong evidence, even though it has existed and been practised for a long time. In the era of evidence-based dentistry it is appropriate to scrutinize such issues. A review of the current literature indicates that conflicting opinions exist concerning a number of common procedures in clinical dentistry, mainly due to a scarcity of good studies with unambiguous results. There is therefore a need for more high-quality clinical research in attempting to reach the goal of evidence-based clinical practice. The dental community should take an active part in this process.
Of the various conservative treatment modalities available for temporomandibular disorders, we believe that therapeutic exercise has a good prognosis, especially for anterior disc displacement without reduction. Since its effectiveness has not been extensively evaluated, we conducted a comparative study to verify the hypothesis that treatment efficacy would not differ for exercise and occlusal splints. Fifty-two individuals with anterior disc displacement without reduction were randomly assigned to a splint or a joint mobilization self-exercise treatment group. Four outcome variables were evaluated: (i) maximum mouth-opening range without and (ii) with pain, (iii) current maximum daily pain intensity, and (iv) limitation of daily functions. All outcome variables significantly improved after 8 weeks of treatment in both groups. In particular, the mouth opening range increased more in the exercise group than in the splint group. This result demonstrates that therapeutic exercise brings earlier recovery of jaw function compared with splints.
Chronic pain conditions such as fibromyalgia (FM) and temporomandibular disorders (TMDs) are accompanied by complex interactions of cognitive, emotional, and physiological disturbances. Such conditions are complicated and draining to live with, and successful adaptation may depend on ability to self-regulate. Self-regulation involves capacity to exercise control and guide or alter reactions and behavior, abilities essential for human adjustment. Research indicates that self-regulatory strength is a limited source that can be depleted or fatigued, however, and the current study aimed to show that patients with FM and TMD are vulnerable to self-regulatory fatigue as a consequence of their condition. Patients (N=50) and pain-free matched controls (N=50) were exposed to an experimental self-regulation task followed by a persistence task. Patients displayed significantly less capacity to persist on the subsequent task compared with controls. In fact, patients exposed to low self-regulatory effort displayed similar low persistence to patients and controls exposed to high self-regulatory effort, indicating that patients with chronic pain conditions may be suffering from chronic self-regulatory fatigue. Baseline heart rate variability, blood glucose, and cortisol predicted persistence, more so for controls than for patients, and more so in the low vs. high self-regulation condition. Impact of chronic pain conditions on self-regulatory effort was mediated by pain, but not by any other factors. The current study suggests that patients with chronic pain conditions likely suffer from chronic self-regulatory fatigue, and underlines the importance of taking self-regulatory capacity into account when aiming to understand and treat these complex conditions.
These results indicate that NAC restores oxidative stress-induced cell death and severe functional impairment in TMJ chondrocytes, and warrant in vivo testing to explore its therapeutic potential as an anti-inflammatory agent.
These apparently contradictory approaches underline a belief that oral surgical trauma or gross malocclusion has a causative role in the onset of TMD. However, there was no overall evidence of a surgical causal etiology or orthognathic therapeutic value. This review emphasizes that it is in the patients' best interest to carry out prospective appropriately controlled randomized trials to clarify the situation.
There is insufficient evidence to support or not support the effectiveness of the reported drugs for the management of pain due to TMD. There is a need for high quality RCTs to derive evidence of the effectiveness of pharmacological interventions to treat pain associated with TMD.
Pain quality, intensity, and gender characteristics were assessed for referred craniofacial pain from dental (n = 359) vs cardiac (n = 115) origin. The pain descriptors “pressure” and “burning” were statistically associated with pain from cardiac origin, while “throbbing” and “aching” indicated an odontogenic cause. No gender differences were found. These data should now be added to those craniofacial pain characteristics already known to point to acute cardiac disease rather than dental pathology, i.e., pain provocation/aggravation by physical activity, pain relief at rest, and bilateralism. To initiate prompt and appropriate treatment, dental and medical clinicians as well as the public should be alert to those clinical characteristics of craniofacial pain of cardiac origin.
Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.
Researchers at the University of North Carolina at Chapel Hill have found a way to halt chronic pain by stealing a key molecule from a major pain pathway. The finding may dramatically reduce chronic pain in many surgical patients.
In a report published online today in Genome Research (http://www.genome.org), researchers have identified a gene associated with susceptibility to chronic pain in humans, signaling a significant step toward better understanding and treating the condition.
The absence of studies on the therapeutic efficacy of MRI and CT on TMJD reinforces the need for investment in decision-making studies; meanwhile, sectional imaging tests should be prescribed with caution, especially when health budgets are limited.
It was concluded that brief treatments can yield significant reductions in pain, life interference and depressive symptoms in TMD sufferers, and that the addition of cognitive-behavioral coping skills will add to efficacy, especially for those low in somatization, or high in readiness or self-efficacy.
A large academic study has demonstrated structural changes in specific brain regions in female patients with irritable bowel syndrome (IBS), a condition that causes pain and discomfort in the abdomen, along with diarrhea, constipation or both.
These study findings show actual structural changes to the brain, which places IBS in the category of other pain disorders, such as lower back pain, temporomandibular joint disorder, migraines and hip pain — conditions in which some of the same anatomical brain changes have been observed, as well as other changes.
There is no evidence about the effects of different types of orthodontic braces for problems associated with the joint between the lower jaw and skull. When the joint between the lower jaw and the base of the skull is not working well (temporomandibular disorders (TMD)), it can lead to abnormal jaw movement or locking, noises (clicking or grating), muscle spasms, tenderness or pain. TMD is very common, and it is believed by some that it may be caused by the occlusion (the way the teeth bite), trauma or psychological stress. There is also a belief that the pain associated with TMD is similar, in that respect, to low back pain and may be related to variations of a person's individual pain perception. Changes in the way the teeth meet can be produced by the use of active orthodontic appliances. This review found that there is no evidence from trials to show that active orthodontic treatment can prevent or relieve temporomandibular disorders adding support to teeth not being part of its cause. It is suspected that we do not know the real cause of TMD at present.
Despite the widespread use of TENS machines, the analgesic effectiveness of TENS still remains uncertain. This has mainly been due to inadequate methodology and reporting in earlier studies but more recent studies of TENS for chronic pain fail to offer necessary improvements in methodological rigour to define the place of TENS in chronic pain management with any certitude. The search process identified 124 studies; 25 met the inclusion criteria for evaluation in this review but there were insufficient extractable data to make meta-analysis possible. New studies of rigorous design and adequate size are needed before any evidence-based recommendations can be made for patients or health professionals.
Migraine headache and temporomandibular disorders represent two conditions that affect a significant portion of the population. The relationship between tension-type headache, formerly called musculo-skeletal headache, and myalgia of the masticatory muscles has been known and demonstrated in many patients. However, few studies show a significant association between vascular headache or migraine and temporomandibular disorders. Increasing evidence suggests a potential link in the etiology and course of these seemingly distinct pain disorders. This paper reviews these two conditions and discusses the possible connection between migraine headache and temporomandibular disorders.
Much of the evidence base for TMJD treatments may be susceptible to systematic bias and most past studies should be interpreted with caution. However, a scatter plot of RCT quality versus year of publication shows improvement in RCT quality over time, suggesting that future studies may continue to improve methods that minimize bias.
Cognative Behavioral Therapy (CBT), either alone or in combination with biofeedback, conservative treatment and/or self-care, can improve outcomes for patients with TMD in secondary care. However, further research is needed to assess its effectiveness in primary care and in management of other chronic orofacial pain conditions. Further, the number of sessions needed, mode of delivery, and cost-effectiveness also remain unclear.
The current study suggests that patients with chronic pain conditions likely suffer from chronic self-regulatory fatigue, and underlines the importance of taking self-regulatory capacity into account when aiming to understand and treat these complex conditions.
The results of this meta-analysis suggest that acupuncture is a reasonable adjunctive treatment for producing a short-term analgesic effect in patients with painful TMD symptoms. Although the results described are positive, the relevance of these results was limited by the fact that substantial bias was present. These findings must be confirmed by future RCTs that improve the methodologic deficiencies of the studies evaluated in this meta-analysis.
We report an interesting case of vertigo and palsies of the right oculomotor and trochlear nerves associated with fluid collection in the region of the ipsilateral temporal lobe and cavernous sinus after bilateral arthroscopy of the temporomandibular joint (TMJ).
The present findings suggest that peripheral glutamate and capsaicin receptor mechanisms interact to affect some jaw motor as well as sensory (i.e. pain) functions and provide new insights into the complexity of orofacial pain. Management approaches that target the peripheral nervous system and receptor mechanisms may prevent such changes in jaw motor function.
The overall goal of this Initiative is to expand the community of researchers engaged in research on temporomandibular disorders (TMJD) and orofacial pain. Several centers of excellence in TMJD research exist. However, an expansion of this field is necessary to reach a critical mass of scientists with new and complementary expertise who will be able to leverage recent advances in genetics, bio-engineering, and bio-behavioral research. The objectives of this Initiative are to 1) increase the number of basic and clinical investigators who are trained in TMJD or orofacial pain research, 2) facilitate and improve the mentoring of this new group of scientists, 3) expand the expertise and scientific disciplines that can be applied to TMJD and orofacial pain research. The expected outcome of this Initiative will be an increased number of multidisciplinary research teams led by new, young investigators. These new teams will form a robust research community applying novel approaches to TMJD and orofacial pain research that will enhance our understanding of the disorders and lead to effective treatments for patients.
The current study showed the existence of multiple active muscle TrPs in the masticatory and neck-shoulder muscles in women with myofascial TMD pain. The local and referred pain elicited from active TrPs reproduced pain complaints in these patients. Further, referred pain areas were larger in TMD pain patients than in healthy controls. The results are also in accordance with the notion of peripheral and central sensitization mechanisms in patients with myofascial TMD.
In the current version (I) of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), imaging of the temporomandibular joint (TMJ) is not required for a diagnosis. Research has shown that radiological findings of the TMJ do not always support the clinical findings of the RDC/TMD diagnosis. But imaging should only be performed when it is known that it could contribute to (i) a proper diagnosis and (ii) treatment with a better prognosis. Several techniques are used to image the TMJ: panoramic radiography, plain radiography, conventional and computed tomography (CT), digital volume tomography or cone-beam computed tomography (CBCT), arthrography and magnetic resonance imaging (MRI). Osseous changes are best visualized in tomography, and the newly developed CBCT is a promising method but must be evaluated in a comparative analysis with other tomographic techniques. And although MRI is the method of choice for imaging the disc, a systematic review found the evidence grade for the diagnostic efficacy of MRI to be insufficient. Today, there is no clear evidence for when TMD patients should be examined with imaging methods. Future research designs should be randomized controlled trials where various radiological examination findings are analysed in relation to therapeutic outcome. In future versions of the RDC/TMD diagnostic system, recommended radiographic techniques must be evaluated and defined, diagnostic criteria well defined and observers calibrated.
Although most cases of temporomandibular muscle and joint disorders (TMJD) are mild and self-limiting, about 10% of TMJD patients develop severe disorders associated with chronic pain and disability. It has been suggested that fibromyalgia and widespread pain play a significant role in TMJD chronicity. This paper assessed the effects of fibromyalgia and widespread pain on clinically significant TMJD pain (GCPS II-IV). Four hundred eighty-five participants recruited from the Minneapolis/St. Paul area through media advertisements and local dentists received examinations and completed the Graded Chronic Pain Scale (GCPS) at baseline and at 18 months. Baseline widespread pain (OR: 2.53, P = .04) and depression (OR: 5.30, P = .005) were associated with onset of clinically significant pain (GCPS II-IV) within 18 months after baseline. The risk associated with baseline fibromyalgia was moderate, but not significant (OR: 2.74, P = .09). Persistence of clinically significant pain was related to fibromyalgia (OR: 2.48, P = .02) and depression (OR: 2.48, P = .02). These results indicate that these centrally generated pain conditions play a role in the onset and persistence of clinically significant TMJD.
This article presents evidence that central processing of innocuous tactile stimulation is abnormal in TMD. Understanding the complexity of sensory disruption in chronic pain could lead to improved methods for assessing cerebral cortical function in these patients.
This systematic review noted moderate evidence that acupuncture is an effective intervention to reduce symptoms associated with TMD. There is a need for acupuncture trials with adequate sample sizes that address the long-term efficacy or effectiveness of acupuncture.J Orofac Pain 2010;24:152-162.
Glutamate evokes immediate pain in the healthy human TMJ that is partly mediated by peripheral NMDA receptors in the TMJ. J Orofac Pain 2010;24:172-180.
Scientists will report results from the first three years of the world's first-ever large, prospective clinical study to identify risk factors that contribute to someone developing a TMJ disorder.
There is some evidence that the following can be effective in alleviating TMD pain: occlusal appliances, acupuncture, behavioural therapy, jaw exercises, postural training, and some pharmacological treatments. Evidence for the effect of electrophysical modalities and surgery is insufficient, and occlusal adjustment seems to have no effect. One limitation of most of the reviewed SRs was that the considerable variation in methodology between the primary studies made definitive conclusions impossible
Stabilization splints are frequently used for the treatment of temporomandibular disorders (TMD) and bruxism, despite the fact that little is known about their mechanism of action or the precise conditions under which they can be recommended. Moreover, information about their possible adverse effects, which in the majority of cases include occlusal modifications of little clinical relevance, is scarce. On occasions, these splints can provoke severe occlusal alterations and other complications, which are rarely alluded to in the literature. Here presented in this paper are three case reports in which part-time stabilization splints led to irreversible occlusal alterations and a discussion of the relevant clinical implications. Such splints are reported to negatively affect the condyle-disk relation in patients who exhibit disk displacement with reduction and to modify breathing features in patients with obstructive sleep apnea, although further studies are required to unequivocally demonstrate these findings. Finally, the splint seems to modify peripheral information at the level of the Central Nervous System, leading to modifications in corporal postural tone. The clinical repercussions of such alterations are currently poorly understood. It is our hope that future research will throw fresh light on these important topics.
Temporomandibular disorders (TMDs) are a common group of chronic illnesses. There is evidence that health professionals find them difficult to diagnose and manage. A consequence of this difficulty in diagnosis might be that sufferers of TMDs have an experience of illness comparable with other chronic illnesses. To explore the sufferers’ experience of TMDs, we conducted a qualitative study with a purposive maximum variation sample of secondary care TMD patients. Semi-structured interviews were conducted with the sample and were recorded and transcribed verbatim. Data collection and analysis continued until data saturation (n = 19). For analysis, we broadly followed the constant comparative method and used frameworks to organize the data. The key finding was that a lack of diagnosis caused uncertainty over the nature of the cause of the sufferer’s complaint. This uncertainty reportedly caused negative impacts on sufferers’ daily lives. Clearly, diagnosis of TMDs needs to be encouraged at the first point of contact.
The AADR recognizes that temporomandibular disorders (TMDs) encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may include difficulties with chewing, speaking, and other orofacial functions. They also are frequently associated with acute or persistent pain, and the patients often suffer from other painful disorders (comorbidities). The chronic forms of TMD pain may lead to absence from or impairment of work or social interactions, resulting in an overall reduction in the quality of life.
Clinical features, pathophysiology, and treatment of medication-overuse headache. Medication-overuse headache (MOH) is a chronic headache disorder defined by the International Headache Society as a headache induced by the overuse of analgesics, triptans, or other acute headache compounds. The population-based prevalence of MOH is 0·7% to 1·7%. Most patients with MOH have migraine as their primary headache and overuse triptans or simple analgesics. The pathophysiology of MOH is still unknown. As well as psychological mechanisms such as operant conditioning, changes in endocrinological homoeostasis and neurophysiological changes have been observed in patients with MOH. Recently, a genetic susceptibility has been postulated. In most cases, treatment of MOH consists of abrupt withdrawal therapy and then initiation of an appropriate preventive drug therapy. There is no clear evidence on which method of withdrawal therapy is the most efficacious. Withdrawal symptoms can be treated with steroids; however, not all data support this concept. As MOH can severely affect the quality of life of patients, it needs to be recognised early to enable appropriate treatment to be initiated.
We report an interesting case of vertigo and palsies of the right oculomotor and trochlear nerves associated with fluid collection in the region of the ipsilateral temporal lobe and cavernous sinus after bilateral arthroscopy of the temporomandibular joint (TMJ).
Evaluation of the reproducibility in the interpretation of magnetic resonance images of the temporomandibular joint. Examiners do not demonstrate reproducibility in the interpretation of MRI of temporomandibular joints. Therefore, more efforts are necessary with respect to understanding the changes that may be detected in these images in terms of diagnosis and appropriate treatment approaches.
Chronic myofascial temporomandibular pain is associated with neural abnormalities in the trigeminal and limbic systems. Myofascial pain of the temporomandibular region (M–TMD) is a common, but poorly understood chronic disorder. It is unknown whether the condition is a peripheral problem, or a disorder of the central nervous system (CNS)...The pattern of gray matter abnormality found in M–TMD individuals suggests the involvement of trigeminal and limbic system dysregulation, as well as potential somatotopic reorganization in the putamen, thalamus, and somatosensory cortex.
Pathophysiology of TMD pain - basic mechanisms and their implications for pharmacotherapy. This article discusses the pathophysiology of temporomandibular disorders (TMD)–related pain and its treatment with analgesic drugs. Temporomandibular disorders are comprised of a group of conditions that result in temporomandibular joint pain (arthralgia, arthritis) and/or masticatory muscle pain (myofascial TMD). In at least some patients with TMD, a peripheral mechanism contributes to this pain. However, there is often a poor correlation between the severity of TMD–related pain complaints and evidence of definitive tissue pathology. This has led to the concept that pain in some patients with TMD may result from altered central nervous system pain processing and further that this altered pain processing may be attributable to specific genes that are heritable. Psychosocial stressors are also thought to contribute to the development of TMD–related pain, particularly masticatory muscle pain. Finally, substantially more women suffer from TMD than men.
The reviewed studies convincingly demonstrated that oral health-related quality of life was negatively affected among TMD patients.
Development of Temporomandibular Disorders is Associated with Greater Bodily Pain Experience. This is a 3–year prospective study of 266 females aged 18 to 34 years initially free of temporomandibular disorders (TMD) pain. All patients completed the Symptom Report Questionnaire (SRQ) at baseline and yearly intervals, and at the time they developed TMD (if applicable)...The development of TMD was accompanied by increases in headaches, muscle soreness or pain, and other pains that were not observed in the Participants who did not develop TMD. Participants who developed TMD also report higher experience of joint, back, chest, and menstrual pain at baseline. Click here to read the abstract.
Smoking and other types of tobacco use may increase the pain of temporomandibular joint disorders, a new study suggests. Click here to view the abstract summary in the publication Pain, December 15, 2009.
Acupuncture promoted alterations in the EMG activity of masticatory muscles, increased maximal molar bite force, and led to remission of the subjects' painful symptomatology.
Orthognathic treatment and temporomandibular disorders: A systematic review. Part 1. A new quality-assessment technique and analysis of study characteristics and classifications Authors' conclusions: The diversity of diagnostic criteria and classification methods used in the included studies makes interstudy comparisons difficult. There is a definitive need for well-designed studies with standardized diagnostic criteria and classification methods for TMD.
Orthognathic treatment and temporomandibular disorders: A systematic review. Part 2. Signs and symptoms and meta-analyses Authors' conclusions: Although orthognathic surgery should not be advocated solely for treating TMD, patients having orthognathic treatment for correction of their dentofacial deformities and who are also suffering from TMD appear more likely to see improvement in their signs and symptoms than deterioration.
Arthrocentesis and lavage for treating temporomandibular joint disorders. Authors' conclusions: There is insufficient, consistent evidence to either support or refute the use of arthrocentesis and lavage for treating patients with temporomandibular joint disorders. Further high quality RCTs of arthrocentesis need to be conducted before firm conclusions with regard to its effectiveness can be drawn.
Bone Graft Grown in Exact Shape of Complex Skull-Jaw Joint.
Temporomandibular joint formation requires two distinct hedgehog-dependent steps. The temporomandibular joint (TMJ) is a unique and highly specialized synovial joint, essential for jaw movement and found only in mammals. Synovial joints are the most common and most movable type of joint in the body, charatcherized for the presence of a lubricating synovial fluid with the joint. (Click here to read more)
Cyclobenzaprine (Flexeril) for the treatment of myofascial pain in adults.
Treatment of Closed Lock of the TMJ. (.pdf) Surgery has long been the treatment of choice, since it was assumed that this was the only way to get the disk back in place. However, it was also known that symptoms can improve with simple symptom management, or a combination of symptom management and physical therapy. This prompted a group at the University of Minnesota to carry out a randomized clinical trial of four treatments for Closed Lock.
The methodological quality of systematic reviews comparing temporomandibular joint disorder surgical and non-surgicaltreatment. (.pdf) BMC Oral Health 2008, 8:27 The results indicate that in spite of the widespread impact of TMJ Disorders, and the multitude of potential interventions, clinicians have expended sparse attention to systematically implementing clinical trial methodology that would improve validity and reliability of outcome measures. With some 20 years of knowledge of evidence-based healthcare, the meager attention to these issues begins to raise ethical issues about TMJ Disorders trial conduct and clinical care.
Cyclobenzaprine for the treatment of myofascial pain in adults. There was insufficient evidence to support the use of cyclobenzaprine in the treatment of myofascial pain (MP). Further studies are needed to show whether cyclobenzaprine really works for treatment MP, but at the moment doctors cannot say whether it is really useful. Cochrane Database of Systematic Reviews.
Inconsistent evidence for the use of tricyclic antidepressants in the treatment of temporomandibular joint disorders. There is evidence, based on inconsistent or limited-quality patient-oriented data (SORT level B recommendation), for the use of tricyclic antidepressants (TCA) in the treatment of temporomandibular joint disorders (TMD).Evidence-Based Dentistry.
There is currently no suitable replacement for the irreversibly damaged temporomandibular joint (TMJ) discs after discectomy.
The effects of cycling levels of 17-estradiol and progesterone on the magnitude of temporomandibular joint (TMJ)-induced nociception. Hormone levels in female rats can affect the perception of pain in the temporomandibular joint (TMJ), providing a possible explanation for the higher incidence of TMJ pain in females, according to a study published online April 9 in Endocrinology.
The goals of this workshop were to (1) finalize the revision of the RDC/TMD into a Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) which would be more appropriate for routine clinical implementation, (2) provide a broad foundation for the further development of suitable diagnostic systems for not only TMD but also orofacial pain as well, and (3) provide research recommendations oriented towards improving our understanding of TMD and orofacial pain.
Botulinum toxin for masseter hypertrophy:. Although the use of botulinum toxin injections might appear to have certain advanctages over surgery the authors in this review did not find any high quality studies evaluating the effectiveness and potential harms of botulinum toxin type A in the management of benign maseter hypertrophy.
The methodological quality of systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment. The results indicate that in spite of the widespread impact of TMJ Disorders, and the multitude of potential interventions, clinicians have expended sparse attention to systematically implementing clinical trial methodology that would improve validity and reliability of outcome measures. With some 20 years of knowledge of evidence-based healthcare, the meager attention to these issues begins to raise ethical issues about TMJ trial conduct and clinical care.
Claims have been made that certain diagnostic devices should be routinely used to differentiate between jaw dysfunction and normal variation and between various pathologic conditions of the temporomandibular joint. The claims that jaw-tracking devices have diagnostic value for detecting TMD are not well supported by the scientific evidence. The clinical usefulness of electromyography devices is limited because of technical, methodologic, and data interpretation problems, as well as significant overlap between asymptomatic and symptomatic groups. Claims for the use of sonography and vibratography machines to discriminate between various intracapsular TMJ conditions have not been substantiated by well-designed research. Until acceptable levels of technical and diagnostic validity have been clearly established, these diagnostic devices cannot be relied on as aids in differential diagnosis or in clinical decision making in the TMD field.
In September 2007 the National Institute of Dental and Craniofacial Research convened a group of thought leaders to determine the best approaches for future basic and clinical research on TMJ Disorders within an integrated systems approach and various options to advance this goal. Click here to read the Final Report of the TMJD Working Group.
Occlusal splints for treating sleep bruxism (tooth grinding). This study found insufficient evidence to either support or refute the use of occlusal splints for treating patients with tooth grinding or clenching during sleep (sleep bruxism) Sleep bruxism is characterised by several signs and symptoms. Among them abnormal tooth wear, fractured teeth, joint pain or tenderness, jaw muscle discomfort, and headaches. Treatments include odontological devices such as occlusal splints, pharmacotherapy, and psychotherapy. An occlusal splint is a removable appliance worn in the upper jaw (maxilla) or the lower jaw (mandible), with coverage of the dental surfaces. They are usually used to prevent tooth wear. There is not enough evidence in the literature to show that occlusal splints can reduce sleep bruxism.
TMJD patients often experience tinnitus – ringing in the ears. The following articles in ScienceDaily indicate tinnitus could be caused by the brain. Researchers Find Sites In Brain Responsible For Tinnitus; Work Raises Possibility Of Treatments, Cure and Searching For The Brain Center Responsible For Tinnitus.
Cartilage engineered with human embryonic stem cells, 9/13/2007, By Eugene J. Koay, Gwen M.B. Hoben, Kyriacos A. Athanasiou
Rice University researchers have engineered musculoskeletal cartilages with human embryonic stem cells (hESCs), with the hope of eventually using the hESC-derived neotissue for the replacement of damaged or diseased cartilages, such as the temporomandibular joint (TMJ) disc, in humans.
The need for cartilage replacements results from the inability of human musculoskeletal cartilages to effectively heal. This can lead to functionally deficient tissue and can result in the clinical syndrome known as arthritis, a major clinical problem with significant social and economic burdens.
Though important progress has been made in recent years toward engineering replacement cartilages in the laboratory, there are still many challenges to address, including the identification of a useful source of cells that can generate the new cartilage. Cartilage tissue engineering requires many cells to produce a piece of tissue that has clinically relevant dimensions, and this requirement far exceeds our current capability to obtain cartilage cells from an individual patient.
Stem cells, from both embryonic and adult sources, may address this particular hurdle, though a great deal of work still needs to be performed. Human embryonic stem cells (hESCs), in particular, have been scarcely studied to date for cartilage applications.
Toward understanding the use of hESCs for generating cartilage, two questions need to be addressed. First, how can the cells be “differentiated” or coaxed into cartilage-producing cells? Second, how can the cells be used for tissue engineering of cartilage?
In a recent study published in the journal Stem Cells, the Rice University researchers, including myself, Ms. Gwen M.B. Hoben, and Professor Kyriacos A. Athanasiou, used National Institutes of Health (NIH)-approved hESCs which were differentiated in conditions with distinct regimens of biochemical agents (growth factors) that are known to have cartilage-inducing properties. The resulting cells were then used in a tissue engineering strategy called self-assembly, which deviates from traditional engineering approaches in that self-assembly does not require any scaffold material to direct the formation of tissue.
This self-assembly approach with the hESC-derived cartilage cells resulted in uniform pieces of cartilage with cellular, biochemical, and biomechanical properties most similar to the TMJ disc and the knee meniscus, which are both fibrocartilages. Interestingly, the cartilages from each distinct biochemical regimen had a unique set of characteristics, suggesting that different types of cartilage can be generated with a single cell source in hESCs.
This study was the first demonstration of the ability of cartilage-differentiated hESCs to “self-assemble” and produce such robust cartilage, though there is still room for improvement. Additionally, the concept of producing multiple types of cartilage with this single cell source is new for the field, as the different cartilages of interest have diverse structures and biomechanical functions.
This initial study sets the ground for new research that seeks to enhance the properties of the hESC-derived cartilage, direct their differentiation for specific cartilage applications, and determine the clinical applicability of these cells, including their safety. This work was funded by an unrestricted fund from Rice University.
Recent findings: There is now reasonably good evidence that myofascial temporomandibular disorder patients are more likely to have a tension-type headache problem and vice versa, but the overlap is not complete. Studies have documented similarities regarding sensitization of the nociceptive pathways, dysfunction of the endogenous pain modulatory systems as well as contributing genetic factors, but there are also a number of distinct differences between temporomandibular disorders and tension-type headaches that need to be considered.
Summary: Using the current classification systems, myofascial temporomandibular disorder pain and tension-type headache disorders do overlap and appear to share many of the same pathophysiological mechanisms, but it would be premature to consider them as identical entities since the importance of, for example, the affected muscles and associated function and genetic background needs to be established. Orofacial pain and headache specialists should collaborate to further develop diagnostic procedures and management strategies of temporomandibular disorders and tension-type headaches.
Researchers at the University of North Carolina at Chapel Hill have discovered that commonly occurring variations of a gene trigger a domino effect in chronic pain disorders. The finding might lead to more effective treatments for temporomandibular joint disorder (TMJD) and other chronic pain conditions.
Catechol-O-methyltransferase (COMT), an enzyme that metabolizes neurotransmitters such as epinephrine, norepinephrine and dopamine and that has been implicated in the modulation of persistent pain, as well as cognition and mood, is regulated by a gene, also called COMT. Previous UNC-led research showed that common genetic variants of this gene are associated with increased pain sensitivity and the likelihood of developing TMJD.
Now, the researchers have discovered that specific variants of the COMT gene can dramatically affect the secondary structure of corresponding messenger RNA - which, in turn, leads to alterations in the amount of enzyme crucial for regulating pain processing. The discovery is published in the Dec. 22 issue of Science.
"TMJD is a complex pain condition that is frequently associated with other pain conditions such as fibromyalgia syndrome, chronic headaches and irritable bowel syndrome," said Dr. William Maixner, director of the Center for Neurosensory Disorders in UNC's School of Dentistry and a study co-author.
"This study has identified a new genetic mechanism that influences an individual's susceptibility to develop chronic pain conditions such as TMJD," Maixner said.
The study was conducted to understand the mechanism by which the identified genetic variants influence enzymatic activity and, ultimately, biological functions such as pain transmission. The researchers found that three major variants of COMT show significant differences in how they code for the secondary structure of messenger RNA, or mRNA. The differences lead to dramatic alterations in protein expression, which substantially influences pain sensitivity in humans.
These findings are clinically important because pain conditions resulting from low COMT activity or elevated catecholamine levels are likely to be susceptible to treatment with pharmacological agents that block beta 2- and beta 3-adrenergic receptors, which mediate COMT-dependent pain signaling, or that control mRNA secondary structure.
"Elucidating the genetic mechanisms that mediate pain perception will provide new insights into how chronic pain develops and will ultimately contribute to the identification of unique markers for diagnosing clinical pain conditions, as well as provide novel targets for the development of effective individualized therapeutics for TMJD and related conditions," said Dr. Andrea Nackley Neely, a research assistant professor in the Center for Neurosensory Disorders and the study's lead author.
"These data have broad medical and evolutionary implications regarding the analysis of variants common in the human population," Nackley Neely said. "It is believed that variants leading to altered protein structure have the strongest impact on gene function. However, this study demonstrates that combinations of common genetic variants that influence mRNA secondary structure may have even stronger effects and, thus, represent another key factor responsible for disease onset and progression."
"This study provides additional evidence of a genetic, molecular and physiological basis for pain perception and human pain conditions and should help to remove the stigma associated with conditions such as TMJD and fibromyalgia," said Dr. Luda Diatchenko, an associate professor in the center and the study's chief investigator.
Other researchers were Dr. Inna Tchivileva, a postdoctoral research associate within the Center for Neurosensory Disorders; Kathryn Satterfield, a former research assistant within the center; Dr. Olex Korchynskyi, a former postdoctoral research associate within the UNC-Chapel Hill School of Medicine's Thurston Arthritis Research Center; Dr. Sergei S. Makarov, a former associate professor at the Center for Neurosensory Disorders and the Thurston center and now president and chief executive officer of Attagene Inc.; and Dr. Svetlana A. Shabalina, a staff scientist with the National Center for Biotechnology Information.
Funding was provided by the National Institute of Dental and Craniofacial Research, National Institute of Child Health and Human Development and National Institute of Neurological Disorders and Stroke, all components of the National Institutes of Health. Additional support came from the Intramural Research Program of the National Center for Biotechnology Information.
Other Center for Neurosensory Disorders research initiatives are currently under way that further explore the genetic basis of pain: One seven-study, a $19-million National Institute of Dental and Craniofacial Research-funded agreement involving multiple institutions and based at the center, will follow 3,200 health individuals and 200 who have facial pain. Titled OPPERA (Orofacial Pain: Prospective Evaluation and Risk Assessment), the study is designed to identify both environmental and genetic factors that increase an individual's susceptibility to TMJD and other chronic pain conditions.
Related link on OPPERA study: https://www.oppera.org/
The Fourth Scientific Meeting of The TMJ Association, A Systems Approach to the Understanding of TMJ as a Complex Disease, set as a top priority the goal of finding and studying the poorly understood relationship between TMJ and other medical conditions. The meeting took place in September in Bethesda, Md., at the Federation of American Societies for Experimental Biology.
Temporomandibular joint diseases and disorders, commonly called TMJ, are a collection of conditions characterized by jaw and facial pain and limitations in jaw movements. Injury and conditions that routinely affect other joints in the body, such as arthritis, may affect the temporomandibular joint.
The National Institute of Dental and Craniofacial Research of the National Institutes of Health estimates that more than 10 million people in the United States suffer from TMJ problems at any given time. While both men and women experience TMJ problems, 90 percent of the most severely affected are women in their childbearing years.
People diagnosed with TMJ may be experiencing other symptoms and medical conditions as part of broader multi-systems illnesses that go unrecognized. Patients with TMJ are most often diagnosed and treated primarily by dentists or oral surgeons, while another medical professional may be treating them for other conditions, such as allergies, headaches, fibromyalgia, cardiac arrhythmias, sleep disorders, movement disorders, tinnitus and irritable bowel syndrome, each treating one of the constellation of conditions without considering the body as a collection of interrelated systems.
"Patients often face bewildering, expensive and unproven treatments that may not help them because the connection between the conditions is not realized," says Terrie Cowley, president and co-founder of the TMJ Association, based in Milwaukee, Wis. "Making the connection between TMJ and these other illnesses could bring better understanding and, as a result, the hope for safer, more effective treatments."
Presenters at The Fourth Scientific Meeting of the TMJ Association included medical and dental clinicians, as well as basic scientists from many disciplines. The top recommendation from the September meeting was to direct the National Institutes of Health to create regional research centers for the study of TMJ disorders and other health conditions by focusing more closely on patients' full set of symptoms, including the "co-morbid conditions" so many TMJ patients exhibit.
The centers should work closely with universities and other agencies to develop basic research projects, while advancing clinical practices for better patient care along with stronger community medical and dental programs and education. Research should include many diverse fields such as endocrinology, neurology, immunology, rheumatology, epidemiology, bioinformatics, genetics and others.
This approach signals a paradigm shift in how TMJ diseases and disorders are studied and treated. Temporomandibular diseases and disorders are complex conditions that may be related to larger health issues that are influenced by genes, gender, environmental triggers, such as trauma, and behavior, the conference concluded.
"It is more important than ever that we understand the full scope of these disorders," said Dr. Allen W. Cowley, Jr., Chair and Professor of Physiology at the Medical College of Wisconsin, Chairman of the Scientific Meeting Planning Committee and husband of Ms. Cowley, the association's president and co-founder.
"For years we have heard many patients say their problems are not well understood and the treatments are not working." Ms. Cowley says. "People who are suffering need help and that's not always possible if their illness is not completely understood." "This conference brings us closer to better understanding why, so we can establish a standard of care for people who are experiencing what we currently call TMJ."
National Institutes of Health Co-Sponsors of The Fourth Scientific Meeting
The TMJ Association's scientific meetings and continuous advocacy for multidisciplinary research have resulted in initiatives from the member agencies of the National Institutes of Health that will lead to multi-disciplinary research specifically focused on TMJ disorders.
A study, published in the Journal of Neurochemistry, identifies a key interaction between head and neck nerve cell proteins that may help shed light on migraines and temporomandibular joint disorders.
Researchers at Oregon Health & Science University's School of Dentistry have uncovered an interaction between two proteins in the nerve cells that carry pain information from the head and neck to the brain. The finding could play a significant role in the development of therapies to cure migraines and other craniofacial pain conditions like TMJ (temporomandibular joint) disorder. According to the National Institutes of Health (NIH), approximately 10 percent of Americans suffer from chronic pain conditions and a significant portion of them have chronic craniofacial pain.
"Our discovery reveals the complexities of pain signaling mechanisms from the head and neck to the brain," said Agnieszka Balkowiec, M.D., Ph.D., principal investigator, OHSU School of Dentistry assistant professor of integrative biosciences and OHSU School of Medicine adjunct assistant professor of physiology and pharmacology.
Head pain is signaled to the brain by what's known as the trigeminal nerve. The trigeminal nerve also conveys other types of sensation, such as touch and temperature, from numerous structures of the face, including skin, ears, cornea, temporomandibular joints and teeth. Studies suggest that the trigeminal nerve provides the signaling pathway for pain associated with migraines, TMJ disorder, periodontal pain, dental surgical pain, trigeminal neuralgia, head and neck cancer pain, and other neuropathic and inflammatory pain conditions.
The OHSU study focused on two trigeminal nerve cell proteins: Calcitonin Gene-Related Peptide (CGRP), and Brain-Derived Neurotrophic Factor (BDNF). Previous studies found that during a migraine attack, the stimulation of trigeminal nerve cells releases CGRP at the peripheral end of the cells, widening blood vessels in the brain coverings called meninges. Widening the blood vessels increases the flow of blood through the meninges and initiates an inflammatory process that likely contributes to the pain experience. Recent clinical studies show that blocking CGRP helps alleviate migraine pain.
The discovery by Balkowiec and her team points to BDNF being a likely culprit behind head pain - a previously unknown finding. The OHSU team found that the stimulation of trigeminal nerve cells, as experienced during a migraine attack, leads to release of not only CGRP, but also BDNF. The study also found that BDNF is released by CGRP when trigeminal nerve cells are not stimulated. In fact, said Balkowiec, CGRP's role at the central end of the trigeminal nerve cells is likely to be the facilitation of BDNF release. BDNF has previously been shown to play an important role in pain signaling from other parts of the body, but this is the first time it has been considered to be a factor in head pain.
"What we now need to better understand is how the interaction between CGRP and BDNF affects pain signaling to the brain in various disorders," said Balkowiec.
Balkowiec's team included School of Medicine doctoral student Ilya Buldyrev; School of Dentistry dental students Nathan Tanner and Loi Nguyen; School of Dentistry research assistant Hui-ya Hsieh; and Oberlin College senior Emily Dodd.
The research at OHSU was funded by grants from the National Institutes of Health, Medical Research Foundation of Oregon, American Association for Dental Research and the OHSU School of Dentistry.
Tinnitus is a sound in one or both ears or in the head when no external sound is present. It is often referred to as "ringing in the ears," although some people hear hissing, roaring, whistling, chirping, or clicking.
The National Institute on Deafness and Other Communication Disorders of the National Institutes of Health hosted a workshop on tinnitus December 5-6, 2005. The purpose of the workshop was to advise the National Institute on Deafness and Other Communication Disorders about research and training opportunities in the area of tinnitus. Linda Parkin, a TMJ patient who also experiences tinnitus, as do many TMJ patients, participated in the meeting. Click here to read the meeting summary.
The Cochrane Oral Health Group reveals common treatments for TMJ pain have not yet been proven to be effective, despite their popularity.
(The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. The main work of the Collaboration is done by approximately fifty Collaborative Review Groups, within which Cochrane Systematic Reviews are prepared and maintained. The Cochrane Oral Health Group aims to produce systematic reviews which primarily include all randomized control trials (RCTs) of oral health. Oral health is broadly conceived to include the prevention, treatment and rehabilitation of oral, dental and craniofacial diseases and disorders.)
As evidenced by recent work on TMJ tissue engineering, there is hope that the difficult problem of regeneration of tissues related to the TMJ may become tractable in the near future. Dr. Kyriacos Anthansiou's group at Rice University in Houston Texas has contributed a short article to the TMJA describing efforts pertaining to tissue engineering the disc of the TMJ.This article explains the basic premise of tissue engineering, which is essentially to create a new tissue in the laboratory to replace damaged tissues that cannot heal on their own.In more serious cases of disc displacement, which usually involve locking of the jaw and pain, the disc becomes so damaged that it cannot be repaired or repositioned with surgery. As a fibrous cartilage, it cannot heal, and therefore we are using tissue engineering as a strategy to replace the disc. The article describes some fundamental properties of the TMJ disc that distinguish it from the types of cartilage found in the knee or in the ear, for example. The type of patients who would be potential candidates are described, as are cutting-edge strategies to generate a healthy, new TMJ disc with the burgeoning science of tissue engineering. The article concludes with a look to the future for this exciting and promising new approach. The aim of this review article is to suggest that rational approaches are now implemented with the ultimate aim being the engineering of the TMJ disc.
Another strategy to tackle the difficult problems associated with TMJ disorders is to use tissue engineering to replace the condyle, or tip, of the jaw bone in the TMJ. It is exactly this that Jeremy Mao is striving to achieve. His teams approach is to replace both the bone and the cartilage on its surface. In recently reported work, they gathered cells from the bone marrow of rats, then exposed them to different environments to encourage them to become either cartilage cells or bone cells. These cells went into separate liquid solutions that were then hardened into the shape of a human condyle by using UV light. Each construct was then implanted under the skin on the back of a mouse for a few months. This creative approach has produced encouraging results, creating regions containing elements characteristic of bone and cartilage. There is much work to do before patients will see a resulting product, as these engineered constructs will still need to be validated for mechanical integrity. However, his group has emerged as a leader in the field and the potential of their work is exciting.
When reading both papers mentioned above, caution needs to be exercised in interpreting the results. The concepts and data described are quite preliminary in nature and have a long way before they can be realized into clinically-applicable modalities.
Dr. Susan Herring states: "Terrie Cowley, the President of the TMJA, has asked me to add a few comments to the TMJ community to accompany the Science profile of my work. This is very appropriate, because the TMJA and Terrie in particular were in part responsible for my entry into TMJ research about 10 years ago. I was invited to talk about animal models for TMJ research at a 1994 NIH workshop that was attended not only by researchers and clinicians, but also by patients, a real wake-up call for me. At first glance, pigs may not seem the most likely model for human TMJ work, but in fact these omnivorous (and hungry!) mammals have teeth, jaw muscles and jaw joints that are remarkably similar to our own. Even the size is about right, so that surgical procedures and implants aimed at humans can be tried out first on pigs. Our studies have shown that the normal (pig) TMJ is a very dynamic biomechanical area. During chewing, the bones of the TMJ receive a variety of rapidly changing forces. The TMJ disc slides on the bones while its shape is simultaneously deformed. The intricate choreography of these movements is easily disrupted by damage to any part of the TMJ, accounting for its vulnerability. Another important consideration is that the mandibular condyle, the bottom bone of the TMJ, is also the major site of growth for the lower jaw. Overloading of the TMJ in a young individual may inhibit growth and add to deformity. It is our hope that understanding how the parts of the joint work and interact with each other will lead to better therapies, more functional prostheses, and perhaps eventually, biological replacements of damaged joints."
Tissue-engineered scaffolding may help the body repair weakened joints. After a lot of wear and tear, the cartilage that has kept the joints running smoothly gives out, and the body has no substitute or repair kit for the valuable tissue. But researchers just might. A bioengineering team has brewed up a liquid polymer gel that can be poured into torn cartilage tissue. Tested on rabbits, the gel adapts to the shape of the tear and becomes the scaffolding for the body's cartilage cells to make new tissue.
"PAIN RESEARCH: Prolonging the Agony", Science Magazine. Researchers are deciphering the biological changes that can turn pain into a debilitating, chronic state--and they are uncovering new targets for potential painkilling drugs.
Robert C. Coghill and colleagues at Wake Forest University Baptist Medical Center used magnetic resonance imaging (MRI) to study the brains of individuals who volunteered in pain studies. The researchers report that the parts of the brain involved in experiencing pain were more active in subjects whose rating of pain was greater (on a 1-to-10 scale) than in subjects reporting less pain, lending further weight to studies that there are inherent differences in human pain sensitivity. The 17 volunteers were subjected to heat applied by a heating pad to the lower right leg. The brain areas affected included the primary somatosensory cortex (which receives input on the location and intensity of pain) and the anterior cingulate cortex, which is associated with the emotional aspects of pain-its unpleasantness and suffering components. The report was published in the Proceedings in the National Academy of Sciences in late June, 2003.
After years of being told they have either dental or mental problems that explain their often-excruciating pain, TMJ sufferers are finally being given validation and hope as the result of new genetic research. A group of University of Michigan neuroscientists has identified a single gene linked to the amount of pain a person can tolerate. The research, reported in the journal Science, shows that how much pain you suffer is due, at least in part, to a gene that affects how many endorphins, or natural painkillers, your body produces. An enzyme called COMT, produced by the gene, metabolizes the brain chemical, dopamine, which acts as a signal messenger between brain cells. The researchers found that people with a defective version of COMT were less able to make endorphins, and therefore likely more sensitive to painful stimuli. PET scans have confirmed that this enzyme is much more active in some people's brains than in others. The activity of the enzyme is at least partially dependent on the copies of the gene inherited from one's parents. The COMT gene that contains the amino acid methionine, or met, is less active than if it contained the amino acid valine, or val. Those people with two copies of the met-COMT gene were likely to suffer the most pain. It is extraordinary news for TMJ patients that there is finally a scientifically proven physiological basis to provide some explanation as to the cause of their pain. Because it is genetically linked, predisposition to heightened pain response can even be inherited. Patients who have been told their suffering is psychological now have evidence that their pain is, in truth, physical. Thanks to the work these researchers and others committed to discovering the physiological sources of pain, especially for TMJ and other related chronic pain diseases, there is new hope for research-based therapies. A simple blood test may, in the future, result in predicting which medications would be most effective for an individual sufferer. The study's authors include Jon-Kar Zubieta, Mary Heitzig, Yolanda Smith, Joshua Bueller, Yanjun Xu, Robert Koeppe, and Christian Stohler of the University of Michigan, and Ke Xu and David Goldman of NIAAA. Dr. Stohler has credited the TMJ Association with helping him to remain persistent in pursuit of this research: "If it were not for the encouragement and education of the TMJ Association, we would have long given up…because we were told that what we were pursuing could not be done." This research was conducted when Dr. Stohler was at the University of Michigan. Currently, Dr. Stohler is the Dean of the University of Maryland Dental School, Baltimore, Maryland. Dr. Stohler is also a Scientific Advisor to The TMJ Association.
Few longitudinal studies have compared hard splints with soft splints for management of TMD pain and dysfunction. We previously reported results from a randomized clinical trial (RCT; n=200) of usual treatment with a conventional flat plane hard acrylic splint (HS) vs. a soft vinyl athletic mouthguard (SS) vs. no splint usual treatment (UT) indicating no differences between groups at 3 month follow up in self reported rates of pain, symptoms or parafunctional habits, or in clinical findings.
STUDY OBJECTIVES: To examine long term outcomes for clinical findings across these three treatment groups participating in a 12 month longitudinal study.
METHODS: Clinical findings were gathered by calibrated examiners using Research Diagnostic Criteria for TMD (RDC/TMD) examination methods. All subjects met criteria for myofacial pain at baseline. Baseline (BL) and 12 month follow up data were compared for HS, SS, and UT groups. Data are present for the 118 SS (HS=47, SS=38, UT=33) for whom 12 month clinical examination data are available.
RESULTS: ANOVA indicate no significant differences (p.25) between the 3 treatment groups at BL or at 12 months for extraoral, intraoral or joint palpation pain, range of motion, joint sounds or for RDC/TMD diagnoses. For example, maximum unassisted opening (mean mm ± s.e.): BL (HS=48.8±1.3, SS=51.4±1.4, UT=50.1±1.4); 12 month (HS=51.5+1.0, SS=51.1.±1.5, UT=53.0±1.2); extraoral muscles palpation summary score (0-48 points): BL (HS=10.6±1.3, SS=10.2±1.4, UT=9.3±1.1); 12 months (HS=4.6±0.9, SS=5.9±1.3, UT=6.2±1.4). Chi-square analyses indicate no significant differences between groups at BL or 12 months for presence of clicking on opening or closing: BL % (HS=46.8, SS=42.1, UT=43.8); 12 month% (HS=57.5, SS=46.0, UT=63.6).
CONCLUSION: In a randomized clinical trial (RCT) testing intraoral splints vs. no splint usual treatment, 12 month follow up found no differences in clinical findings for range of motion, muscle or joint palpation pain or clicking among hard, soft, or non-splint subjects. These data indicate that for the long term clinical outcomes examined, neither the more costly hard acrylic splint (HS) or the less expensive soft vinyl athletic mouthguard (SS )is superior to non-splint therapy(UT).
Research support by National Institute of Dental Research (NIDR) Grant DE08773
Randomized clinical trials (RCTs) of conservative TMD treatments are uncommon. Subjects were 200 clinic patients meeting RDC criteria for myofascial pain (MFP) enrolled in a 12 month RCT of a conventional flat plane hard acrylic splint (HS) vs. a low cost soft vinyl athletic mouthguard (SS) vs. conservative TMD treatment without a splint (UT). Three month data were previously reported and demonstrated no significant differences in clinical findings or self report measures.
STUDY OBJECTIVES/METHODS: To compare self report findings after a 12 month treatment period. Data are presented for 168 (HS=65, SS=55, UT=48) subjects (84% response rate) for whom 12 month questionnaire data are available.
RESULTS: No significant differences between groups were observed in mean pain levels (0-10 scale) at 12 months or in mean change in pain from baseline to 12 months. (ANOVE, p>.05). However, a significant decrease in pain was observed for all groups (mean change ±s.e.) HS=2.4±0.3, SS=2.6 ±0.3, UT=2.4 ±0.4 (paired t test, Bonferroni p<.0001). No significant differences were found between groups for change in other TMD symptoms (TMJ sounds, eating difficulty, tinnitus, clenching/bruxism, or jaw locking/catching; X2, p>.05).
CONCLUSION: Of randomized clinical trial subjects followed up at 12 months, all three treatments yielded similar levels of reported pain reduction and of non-painful jaw symptoms in all major outcome categories. These data suggest that treatments using lower cost alternatives conservative TMD treatment without a splint (UT) or a low cost soft vinyl athletic mouthguard (SS) to hard splints, provide levels of pain control and symptom reduction equivalent to more costly splint therapy even over an extended period of time. Further research may confirm that these alternatives should be considered as the primary treatment in myofascial pain and may be the only treatment needed by most patients.
Research support by National Institute of Dental Research (NIDR) Grant DE08773
The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial. Oral splints are widely used in the treatment of myofascial pain of masticatory muscles, even though their mechanism of action is unknown. The present study evaluated the therapeutic efficacy of splints using a parallel, randomized, controlled and blind design. Following a sample size estimation, 63 subjects were recruited and assigned to 3 groups: (1) passive control: full occlusal splint worn only 30 minutes at each appointment; (2) active control: palatal splint worn 24h/day; and (3) treatment: full occlusal splint worn 24h/ day. On each of 7 visits over 10 weeks, subjects rated on 100 mm visual analogue scales their pain intensity and unpleasantness at rest and after experimental mastication. The effect of pain on the quality improved for all 3 groups. However, there were no significant differences between groups in any of the variables.These data suggest that the gradual reduction in the intensity and unpleasantness of myofascial pain, as well as the improvement of quality of life during the trial, was non-specific and not related to the type of treatment.
To view or order a free booklet about TMJ Disorders, visit the National Institutes of Health website.
Site operated by The TMJ Association, Ltd. (TMJA) is a non-profit, 501(c)(3) tax exempt organization. ©2009-2010 The TMJ Association, Ltd. All rights reserved.
The TMJ Association, Ltd., P.O. Box 26770, Milwaukee WI 53226. Phone: 262-432-0350. E-mail: info@tmj.org.
This website is for general informational purposes only. It does not constitute professional medical advice, diagnosis, or treatment. This website is not a substitute for such advice, diagnosis, or treatment. You should always consult your doctor if you have questions about your health condition or before starting any treatment. The TMJA is unable to provide doctor referrals and does not endorse any particular health care professional or organization. Reliance on any information provided by TMJA, TMJA employees, others appearing on the website at the invitation of TMJA, or other visitors to the website is solely at your own risk.
Site Designed and Developed by 11th Hour Solutions, LLC