A systematic review of different substance injection and dry needling for treatment of temporomandibular myofascial pain

Temporomandibular myofascial pain presents a major challenge in the diagnosis of temporomandibular disorders (TMD). Due to the characteristics of this condition, intramuscular injection procedures are often needed for adequate control of symptoms and treatment. Thus, the aim of this systematic review was to evaluate the effectiveness of dry needling and injection with different substances in temporomandibular myofascial pain. Electronic databases PubMed, EMBASE, CENTRAL/Cochrane, Lilacs, Scopus, Web of Science and CAPES Catalog of Dissertations and Theses were searched for randomized clinical trials until January 2018. Manual search was performed in relevant journals and in the references/citations of the included studies. The selection of studies was carried out by two independent reviewers according to eligibility criteria. From 7128 eligible studies, 137 were selected for full-text analysis and 18 were included. Due to the heterogeneity of the primary studies it was not possible to perform a meta-analysis. The narrative analysis of the results showed that most of the studies had methodological limitations and biases that compromised the quality of the findings. Dry needling and local anaesthesic injections seem promising, but there is a need to conduct further randomized clinical trials, with larger samples and longer follow-up times, to evaluate the real effectiveness of the technique and evaluated substances.     

Anxiety and personality traits in patients with muscle related temporomandibular disorders

This study tested the hypothesis that muscle related temporomandibular disorder patients with cervical muscle pain exhibit greater degree of psychological distress compared with patients without cervical muscle pain and controls. Thirty-eight muscle related temporomandibular disorder patients including 10 patients with cervical muscle pain and 41 healthy individuals as controls participated in the study. State and trait anxiety levels were assessed with the Spielberger's state and trait anxiety inventory. Personality traits (extroversion, neuroticism, psychoticism and social desirability) were assessed using the Eysenck's personality questionnaire, and the pain intensities described over the muscles were recorded using a 100 mm visual analogue scale. The muscle related temporomandibular disorder patients, in general, exhibited significantly higher degrees of neuroticism and trait anxiety. The patients with cervical muscle pain demonstrated a significantly higher level of psychoticism compared with the patients without cervical muscle pain and the controls and a significantly higher state anxiety level than the controls. They also demonstrated higher pain intensities in masseter and temporalis muscles compared with patients without cervical muscle pain. It has been suggested that either subjects with psychological distress are prone to temporomandibular disorders, or psychological distress is a manifestation of existing chronic pain conditions. The present findings demand further investigations and broader approach in management, as muscle related temporomandibular disorder patients with cervical muscle pain were both physically and psychologically compromised to a greater degree compared with patients without cervical muscle pain.     

Electromyographic evaluation of masseter and anterior temporalis muscles in patients with temporomandibular disorders following interocclusal appliance treatment

The purpose of this study is to evaluate the interocclusal appliance efficiency in patients with temporomandibular disorder (TMD), by using computerized electromyographic (EMG) evaluation in the rest position of the mandible. Twenty-two patients (male and female) with TMD symptoms, between 18 and 53 years of age, were examined. EMG evaluations were performed before the treatment and during the 90th, 120th and 150th day of using the interocclusal appliance therapy. In the 90th and 120th day, inserting canine guidance and group function disclusion, respectively, changed interocclusal appliance. The results showed that group function disclusion caused shorter EMG activity in the mandible rest position for the anterior temporalis muscle.     

Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders

The present study tested the hypothesis that the resting electromyographic (EMG) activities of sternocleidomastoid and trapezius muscles of myogenous temporomandibular disorder (TMD) patients would be significantly greater than healthy individuals. Eight masticatory muscle pain patients without disc interference disorders (DID) and 30 patients with DID along with 41 matched control subjects were included in the study. The resting EMG activities of sternocleidomastoid and trapezius muscles were recorded with a portable EMG machine. Pain intensities described over the muscles were recorded with a 100 mm visual analogue scale. The two groups of patients had significantly higher resting activities compared with control subjects. Patients (in both groups) who had pain in sternocleidomastoid and trapezius muscles reported significantly higher resting activities in the respective muscles than patients who were free of pain and the controls. The presence of pain over the examined muscles showed significant association with the myogenous TMDs without DID. The observed association of the cervical muscles with myogenous TMDs is expected to be a result of functional link between masticatory and cervical muscles. The present findings suggest that the myogenous TMDs without DID could be a distinct sub-group that can be a part of broader regional or generalized diseased entity.     

咬合板对颞下颌关节紊乱病相关颌面部疼痛的影响

颞下颌关节紊乱病（temporomandibular disorders, TMD）是口颌面部慢性痛的主要来源,严重干扰日常活动。咬合板是颞下颌关节紊乱病的最常用的治疗方法之一,但其疗效尚未完全明了。学者们多年来致力于对咬合板的作用机制、疗效的研究,但至今尚未得出统一的结果。该文将对咬合板的作用机制、咬合板的分类、TMD相关疼痛的种类与咬合板的选择、TMD的其他保守治疗与咬合板的关系四个方面对于咬合板治疗颞下颌关节紊乱病相关颌面部疼痛的疗效进行进行综述。     

Ultrasonography as a tool for evaluating treatment of the masseter muscle in temporomandibular disorder patients with myofascial pain

Objectives This study clarified ultrasonography (US) changes after splint therapy and investigated the use of this modality for evaluating treatment of the masseter muscle in temporomandibular disorder (TMD) patients with myofascial pain. Methods Twenty-five female TMD patients with myofascial pain were examined with US before and after splint therapy. The thickness and internal appearance of the masseter muscle were evaluated. Results No differences in thickness were found before and after treatment in either “Improved” or “Not improved” patients. Twelve patients showed changes in the internal appearance. A significant difference was observed in the distributions of types of internal appearance before and after treatment. Three representative cases are presented. Conclusions US has potential for evaluating the masseter muscle in TMD patients with myofascial pain, especially muscles that appear edematous before treatment.     

Treatment outcome of appliance therapy in temporomandibular disorder patients with myofascial pain after 6 and 12 months

Aim: To compare the long‐term effect of treatment with a stabilization appliance (group T) and treatment with a control appliance (group C) in temporomandibular disorder (TMD) patients with myofascial pain. Methods: In this controlled trial, 60 patients (mean age 29 years) with myofascial pain were evaluated after 10 weeks of treatment with either a stabilization appliance or a control appliance. All 60 patients were then assigned to 1 of 3 groups according to demand for treatment. Seventeen patients from group C requested another appliance and were given a stabilization appliance, thus creating a mixed group (group M). Results: A significant difference in improvement of overall subjective symptoms in an intent‐to‐treat analysis between groups T and C was found at the follow‐ups. In a survival analysis of treatment compliance, a significant difference was found between groups T and C. At the 6‐ and 12‐month follow‐ups, a significant reduction in myofascial pain, as measured on a visual analog scale, was found in all three groups. A significant decrease in frequency and intensity of myofascial pain was found in group T at the follow‐ups. A significant decrease in number of tender sites on the masticatory muscles was found in group T at the follow‐ups. Conclusion: The results support the conclusion that the positive treatment outcome obtained by use of a stabilization appliance to alleviate the signs and symptoms in patients with myofascial pain persisted after 6 and 12 months. Most patients in groups T and M reported positive changes in overall subjective symptoms in this trial. We therefore recommend use of the stabilization appliance in the treatment of TMD patients with myofascial pain.     

Development of a speech‐discriminating electromyogram system for routine ambulatory recordings for the low‐level masseter muscle activity

Previous work suggests a relationship between sustained low‐level tooth clenching and the aetiology of myogenous temporomandibular disorder (TMD) pain. This study aimed to establish a reliable system with which to evaluate low‐level electromyographic (EMG) activity related to low‐level tooth clenching while discriminating speech activity, which is one of the most common facial muscle activities to be discriminated from low‐level clenching. This device should facilitate the clinical evaluation of awake muscle activity in TMD patients. Eight female and eight male subjects (38·9 ± 11·3 years) participated in the study to evaluate the validity of estimation of speech duration. Actual speech duration was defined by one examiner by pointing out the timing of beginning and end point of each speech on wave‐editing software. Speech duration, as detected by a voice sensor system, which was activated by a voice loudness of 54·71 ± 5·00 dB, was significantly correlated with the above actual speech duration (P < 0·01, R² = 0·9935). An actual recording with the system was carried out in one TMD patient and one healthy volunteer and revealed that the duration of diurnal EMG activity higher than 5% MVC was 1649·16 s and 95·99 s, respectively. As the voice sensor system adopted in this study could define the exact onset and offset of each segment of speech, EMG activity during speech could be precisely discriminated. The results of this study demonstrate that the EMG system with voice sensor system would be an effective tool for the evaluation of low‐level masticatory muscle activity.     

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

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

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

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

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

颞下颌关节紊乱病患者疼痛的临床描述分析

目的通过研究颞下颌关节紊乱病（TMD）患者对疼痛的主观描述情况,分析TMD患者疼痛的特点。方法选择以口颌面部疼痛为主诉的TMD患者90例为研究对象,检测患者疼痛的强度和相关功能丧失的程度,记录患者自述的疼痛规律和描述疼痛的词汇。结果90例患者主要为轻到中等强度的疼痛,男女之间以及急、慢性期之间疼痛强度的差异无统计学意义（P>0.05）。TMD疼痛对咀嚼功能的影响最大,其次是对心情状况有比较大的影响。急、慢性期患者下颌静止时疼痛出现率无统计学差异（P>0.05）。急性期患者常用酸痛、隐痛、刺痛和抽着痛来描述疼痛,慢性期患者常用的词汇是钝痛、木痛和胀痛。结论急、慢性期TMD导致的疼痛强度均较低,主要影响患者的咀嚼功能和心理状态。急、慢性TMD疼痛的描述词汇有所不同。     

Frequency of temporomandibular arthralgia among myofascial pain patients with pain on palpation of ipsilateral masseter

Aims:

The masseter muscle is a common source of referred pain to the temporomandibular joint (TMJ), with a possibility of false positive diagnoses for arthralgia when diagnosed by research diagnostic criteria for temporomandibular disorders (RDC/TMD) clinical examination. The current study investigated the distribution of arthralgia diagnoses among individuals with myofascial pain, with or without pain on masseter palpation.

Methodology:

The study was conducted with 255 outpatients. Clinical data and questionnaires were directly entered into software that deploys algorithms based on the diagnostic criteria of the RDC/TMD, and automatically classifies and stores the diagnosis of each patient evaluated. An association between diagnostic subgroups was verified by calculating the odds ratio (OR), and the statistical significance was tested using the Chi-square test.

Results:

A higher frequency of concordance (about three times greater) between myofascial pain and arthralgia occurred when there was pain on palpation in the region of the ipsilateral masseter muscle, and the association was statistically significant.

Conclusions:

The results of this study revealed a threefold increase in the risk for the presence of temporomandibular arthralgia in cases of myofascial pain combined with pain on palpation in the region of the ipsilateral masseter muscle.     

The effectiveness of splint therapy in patients with temporomandibular disorders: A systematic review and meta-analysis

PURPOSE: The authors conducted a systematic review of all published randomized controlled trials in which investigators compared the effectiveness of splint therapy with that of minimal or no treatment in patients with temporomandibular disorders (TMDs). TYPES OF STUDIES REVIEWED: The authors searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials for studies published from inception of each database through August 2011. In eligible studies, investigators enrolled adult patients with TMDs and assigned them randomly to splint therapy or a control group receiving minimal or no treatment. RESULTS: Of 1,567 potentially eligible studies, 11 proved eligible and were included. Moderate-quality evidence suggests that splint therapy reduced pain in the temporomandibular joint (TMJ) area (standardized response mean = -0.93, 95 percent confidence interval [CI], -1.33 to -0.53; risk difference for having continued pain = -0.35, 95 percent CI, -0.21 to -0.46; mean change on the 100-millimeter visual analog scale = -11.5 mm, 95 percent CI, -16.5 mm to -6.6 mm). Low to very low quality of evidence showed no significant differences between the splint therapy and control groups in terms of quality of life or depression. None of the trial reports described effect on function. CONCLUSIONS: Although overall results are promising for the reduction of pain, establishing the role of splints for patients with TMDs will require large trials with stronger safeguards against bias.     

Prevalence of self-reported symptoms related to temporomandibular disorders in an Italian population

The aim of this study was to estimate the prevalence of temporomandibular disorders (TMD) symptoms in an Italian population sample, focusing on gender and age differences. We selected 2005 individuals by telephone survey and asked them about TMD symptoms like difficulty in jaw movement, jaw pain and joint sounds. Also, tooth-clenching and/or tooth-grinding habits were investigated. Of the study population, 8·1% reported limitations in jaw movements, 5·1% reported jaw pain and 33·3% reported joint sounds. Furthermore, 37·3% reported tooth-clenching/tooth-grinding. Confidence intervals of proportions were calculated. Significant gender differences were found for jaw limitation and pain (chi-square test; P < 0·05). Symptoms reduced with increasing age. The prevalence of TMD symptoms in the Italian population was consistent with data reported from similar studies. Gender and age differences were found for jaw pain and limitation in jaw movements.     

Prevalence of myofascial temporomandibular disorder in US community women

This study estimates the prevalence of the myofascial subtype of temporomandibular disorders (M-TMD) defined by Research Diagnostic Criteria (RDC), and relates that prevalence to the surveyed report of facial pain. From among 20 000 women selected at random in the NY metropolitan area who completed a telephone survey of facial pain, 2000 were invited for an RDC/TMD examination; 782 examinations were completed. Prevalence was estimated in analyses that were weighted to correct sampling biases. Differences among demographic strata were evaluated with logistic regression. The prevalence of M-TMD was estimated to be 10.5% (95% CL = 8.5-13.0%). Prevalence was significantly higher among younger women, among women of lower socio-economic status, among Black women, and among non-Hispanic women. The report of facial pain in the telephone survey (10.1%) had high specificity for M-TMD diagnosis (94.7%), but low sensitivity (42.7%). M-TMD is a fairly common disorder among American women. Among those reporting facial pain during the last month, half met RDC palpation criteria for M-TMD; thus, a formal physical examination is imperative to establish this diagnosis. Prevalence varies with age, socio-economic status, race and Hispanic ethnicity. A substantial number of RDC-diagnosed cases of M-TMD did not report facial pain in the survey; the reason for this requires further study.     

Effect of hypnosis on oral function and psychological factors in temporomandibular disorders patients

Summary This study investigated the effect of hypnosis in patients with temporomandibular disorders (TMD) with focus on oral function and psychological outcomes. Forty women (mean age ± s.d.: 38·6 ± 10·8 years) suffering from TMD (mean duration 11·9 ± 9·9 years) were randomized to four individual 1‐hour sessions of either hypnotic intervention or a control condition of simple relaxation. Pain intensity was assessed three times daily on a 0–10 Numerical Rating Scale. Additional outcomes were TMD‐associated symptoms assessed by the Research Diagnostic Criteria examination form and questionnaire, psychological symptoms (Symptom Check List 60), pain coping strategies (Coping Strategies Questionnaire), sleep difficulties (Pittsburgh Sleep Quality Index) and use of analgesics. Data were analyzed with between‐groups within‐subjects anova s. The hypnosis group significantly reduced the daily NRS pain scores from 4·5 ± 2·1 at baseline to 2·9 ± 2·4 after treatment (P < 0·001) compared to the control group where no significant changes were found (4·2 ± 1·4 to 3·9 ± 1·5) (P = 0·733). Number needed to treat for a 50% pain reduction was 4·0. The hypnosis group also increased use of the coping strategy ‘reinterpreting pain sensations’ from 5·2 ± 6·9 to 10·3 ± 6·8 (P < 0·001). Both groups exhibited significant reductions in the number of painful muscle palpation sites and pain on palpation (P < 0·004), in number of awakenings due to pain (P < 0·006), and in somatization, obsessive compulsive symptoms and anxiety (P < 0·004). Hypnosis thus appears to effectively reduce some aspects of complex TMD pain.     

Masticatory muscle sleep background electromyographic activity is elevated in myofascial temporomandibular disorder patients

Despite theoretical speculation and strong clinical belief, recent research using laboratory polysomnographic (PSG) recording has provided new evidence that frequency of sleep bruxism (SB) masseter muscle events, including grinding or clenching of the teeth during sleep, is not increased for women with chronic myofascial temporomandibular disorder (TMD). The current case–control study compares a large sample of women suffering from chronic myofascial TMD (n = 124) with a demographically matched control group without TMD (n = 46) on sleep background electromyography (EMG) during a laboratory PSG study. Background EMG activity was measured as EMG root mean square (RMS) from the right masseter muscle after lights out. Sleep background EMG activity was defined as EMG RMS remaining after activity attributable to SB, other orofacial activity, other oromotor activity and movement artefacts were removed. Results indicated that median background EMG during these non‐SB event periods was significantly higher (P < 0·01) for women with myofascial TMD (median = 3·31 μV and mean = 4·98 μV) than for control women (median = 2·83 μV and mean = 3·88 μV) with median activity in 72% of cases exceeding control activity. Moreover, for TMD cases, background EMG was positively associated and SB event‐related EMG was negatively associated with pain intensity ratings (0–10 numerical scale) on post‐sleep waking. These data provide the foundation for a new focus on small, but persistent, elevations in sleep EMG activity over the course of the night as a mechanism of pain induction or maintenance.     

Comorbidity of internal derangement of the temporomandibular joint and silent dysfunction of the cervical spine

The aim of this evaluation was to examine correlations between internal derangement of the temporomandibular joint (TMJ) and cervical spine disorder (CSD). A prospective controlled clinical study was carried out. Thirty patients with signs and symptoms of internal derangement but without any subjective neck problems and 30 age- and gender-matched control subjects without signs and symptoms of internal derangement were examined. The investigation of the temporomandibular system was carried out using a 'Craniomandibular Index'. Afterwards an examiner-blinded manual medical investigation of the craniocervical system was performed. This included muscle palpation of the cervical spine and shoulder girdle as well as passive movement tests of the cervical spine, to detect restrictions in the range of movement as well as segmental intervertebral dysfunction. The internal derangement of the TMJ was significantly associated with 'silent' CSD (t-test, P < 0.05). Patients with raised muscle tenderness of the temporomandibular system exhibited significantly more often pain on pressure of the neck muscles than patients without muscle tenderness of the temporomandibular system (t-test, P < 0.05). As a result of the present study, for patients with internal derangement of the TMJ an additional examination of the craniocervical system should be recommended.