Soft versus hard occlusal splint therapy in the management of temporomandibular disorders (TMDs)

Aim

To compare between soft and hard occlusal splint therapy for the management of myofacial pain dysfunction (MPD) or internal derangement (ID) of the temporomandibular joint (TMJ) with reciprocal clicking.

Patients and methods

This study included 50 patients (age range: 24–47 years) who had been diagnosed with MPD or ID of the TMJ in the form of reciprocal clicking. Patients were divided into two groups. They were treated for 4 months with either a vacuum-formed soft occlusal splint constructed from 2-mm-thick elastic rubber sheets (soft splint group) or a hard flat occlusal splint fabricated from transparent acrylic resin (hard splint group). Monthly follow-up visits were performed during the treatment period. Before treatment and 1, 2, 3 and 4 months after treatment, the dentist measured all parameters of TMJ function (pain visual analog scores, tenderness of masticatory muscles, clicking and tenderness of the TMJ, and range of mouth opening).

Results

All parameters of TMJ function showed significant improvement in both groups during the follow-up period, with a statistically significant difference between the two groups at the 4-month follow-up visit.

Conclusions

Both forms of occlusal splints (soft and hard) improved TMJ symptoms in patients with MPD or ID of the TMJ. However, the soft occlusal splints exhibited superior results after 4 months of use.     

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。     

Clinical factors affecting the outcome of occlusal splint therapy of temporomandibular joint disorders

The purpose of this study was to test the hypothesis that (1) the presence of a clinical temporomandibular joint-related disorder has effects on short-term changes in temporomandibular joint pain, and that (2) clinical variables of time since pain onset predict treatment outcomes of occlusal splint therapy. The study comprised 76 patients with unilateral temporomandibular joint pain. The clinical disorder subgroup included 47 patients with a clinical pain side-related diagnosis of internal derangement type I (n = 16), internal derangement type III (n = 19), and degenerative joint disease (n = 12). The clinical non-disorder subgroup consisted of 29 patients without a temporomandibular joint disorder. A logistic regression analysis was used to compute the odds ratio for the clinical variables of time since pain onset, adjusted for age, gender, pretreatment pain level, and clinical subgroup. For the temporomandibular joint pain measurements there was no significant 'session'/'clinical subgroup' interaction (P = 0.470). Significant increase in benefit of a successful outcome of 'pain reduction >70%' occurred with a time since pain onset of 2 years might belong to the unsuccessful treatment group of 'pain reduction <30%' was strong (6.0) and significant (P = 0.026). Diagnosis of temporomandibular joint disorder proved not to be linked to changes in therapeutic outcome measures of temporomandibular joint pain. Time since pain onset was an important prognostic determinant of successful occlusal splint therapy.     

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.     

Efficacy of stabilisation splint treatment on temporomandibular disorders

Summary The evidence supporting the use of stabilisation splints in the treatment of temporomandibular disorders (TMD) is scarce and a need for well‐controlled studies exists. The aim of this randomised, controlled trial study was to assess the efficacy of stabilisation splint treatment on TMD. The sample consisted of 80 consecutive referred patients who were randomly assigned to the splint group (n = 39) and the control group (n = 41). Subjects in the splint group were treated with a stabilisation splint, whereas subjects in the control group did not receive any treatment except counselling and instructions for masticatory muscle exercises which were given also to the subjects in the splint group. Outcomes were visual analogue scale (VAS) on facial pain intensity and clinical findings for TMD which were measured at baseline and after 1‐month follow‐up. The differences in change between the groups were analysed using regression models. Facial pain decreased and most of the clinical TMD findings resolved in both of the groups. The differences in changes in VAS or clinical TMD findings between the groups were not statistically significant. The findings of this study did not show that stabilisation splint treatment in combination with counselling and masticatory muscle exercises has additional benefit in relieving facial pain and increasing the mobility of the mandible than counselling and masticatory muscle exercises alone in a short time‐interval.     

Diclofenac sodium and occlusal splint therapy in TMJ osteoarthritis: a randomized controlled trial

The aim of the study was to compare treatment with diclofenac sodium (Voltaren 3 x 50 mg) to occlusal splint therapy in a randomized, single-blind controlled trial of patients with a diagnosis of temporomandibular joint (TMJ) osteoarthritis (OA) in accordance with Research Diagnostic Criteria for temporomandibular disorders. Patients with general joint disorders or restrictions against medication with non-steroidal anti-inflammatory drug were not included. Twenty-seven females and two males (aged 36-76 years) included, answered a standardized questionnaire and were clinically examined and they underwent TMJ tomography. The treatment was randomized to either splint (n = 15) or diclofenac (n = 14). The temperatures over the TMJs were determined. The patients were re-examined 1 week, 1 month and 3 months after the start of treatment. A 1-year follow-up was carried out using questionnaires. After 1 week of treatment with diclofenac, significant reductions of pain and discomfort, TMJ tenderness and joint pain on jaw movements were noted. The splint therapy gave a significant reduction of reported symptoms after 1 month of treatment. Both treatments gave few adverse effects and were on an equal level. Estimation of the degree of inflammation by measuring the surface temperature over the TMJ was not reliable. Structural changes of the symptomatic TMJs were radiographically found in 82%, the contralateral, symptom-free TMJ had changes in 36%. There was a discrepancy between the clinical and the radiographical findings. Diclofenac gave a more rapid improvement, but both treatments gave a significant reduction of symptoms of TMJ OA within 3 months which remained at the one-year follow-up.     

Effect of occlusal splint and transcutaneous electric nerve stimulation on the signs and symptoms of temporomandibular disorders in patients with bruxism

A crossed-design experimental study has been made involving simple blind paired data and random assignment to treatment, with the aim of evaluating the action of an occlusal splint with transcutaneous electric nerve stimulation (TENS) upon the manifestations of temporomandibular disorders (TMD) in patients with bruxism. The prevalence of TMD in the 24 patients with bruxism was 62.5%%; the corresponding severity, as determined by the pantographic reproducibility index (PRI), was mild (mean value: 20.71). Clicking and pain in the lateral pterygoid muscle were the most frequent clinical manifestations. The occlusal splint and TENS did not significantly improve the signs and symptoms of TMD in these patients with bruxism.     

认知行为疗法治疗颞下颌关节紊乱病随机对照试验的质量评价

目的 评价认知行为疗法(CBT)治疗颞下颌关节紊乱病(TMD)随机对照试验的方法学质量和报告质量.方法 计算机检索Medline (Ovid平台)、荷兰医学文摘、Cochrane图书馆临床随机对照试验库、中国生物医学文献数据库和中国期刊全文数据库,手工检索5种中文口腔医学杂志,收集CBT治疗TMD的随机对照试验和半随机...     

Evaluation of different occlusal splints and counselling in the management of myofascial pain dysfunction

Summary  The aim of this study was to compare the effectiveness of different occlusal splints associated with counselling and self-care in the management of signs and symptoms of myofascial pain. In a double-blind controlled clinical trial, 42 myofascial pain patients with chief complaint of pain in the masseter muscle area were randomly assigned to 1 of the 3 experimental groups: hard (HS), soft (SS) or non-occluding (NS) occlusal splints. The Modified Symptom Severity Index (Mod-SSI) and tenderness to palpation were used as outcome measures during a 90-day follow-up. All patients improved over time and all splints offered the benefit. The results showed that all the three different appliances (HS, SS, and NS) associated with counselling were able to equally reduce the Mod-SSI (symptoms-Tukey test) and digital palpation (signed Kruskal–Wallis) test between baseline and 90 days.     

Evaluation of the short-term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles

BackgroundThe authors conducted a clinical trial to compare the effectiveness of an education program with that of an occlusal splint in treating myofascial pain of the jaw muscles across a short period.MethodThe authors assigned 44 patients randomly to two treatment groups; 41 patients completed the study. The first group (four male, 19 female; mean [standard deviation {SD}] age, 31.4 [14.0] years) received information regarding the nature of temporomandibular disorder (TMD) and self-care measures, whereas the second group (five male, 13 female; mean [SD] age, 31.1 [8.8] years) received an occlusal splint. One of the authors evaluated each patient every three weeks during a three-month treatment period. Treatment outcomes included pain-free maximal mouth opening, spontaneous muscle pain, pain during chewing and headache.ResultsAfter three months, changes in spontaneous muscle pain differed significantly between the education and occlusal splint groups (P = .034; effect size = 0.33). Changes in pain-free maximal mouth opening did not differ significantly between groups (P = .528; effect size = 0.20). Changes of headache and pain on chewing did not differ significantly between groups (P ≥ .550, effect size ≤ 0.10).ConclusionsDuring a short period, education was slightly more effective than an occlusal splint delivered without education in reducing spontaneous muscle pain in patients with TMD. Pain-free mouth opening, headache and pain during chewing were not significantly different between the two treatments.     

The hierarchy of different treatments for arthrogenous temporomandibular disorders: A network meta-analysis of randomized clinical trials

PurposeDifferent treatment options for patients with arthrogenous Temporomandibular Disorders (TMDs) have been reported. However, evidence regarding the most effective intervention using network meta-analysis (NMA) has not been performed. Thus, we conducted a NMA of randomized clinical trials (RCTs) to identify the most effective treatment of arthrogenous TMDs with respect to pain reduction and improved mouth opening, and to generate a ranking according to their effectiveness.Material and methodsAn electronic search on three major databases was undertaken to identify RCTs published before August 2019, comparing up to fourteen different treatments against control/placebo patients for arthrogenous TMDs with respect to pain reduction and improved mouth opening. The treatment variables were controls/placebo, conservative treatment (muscle exercises and occlusal splint therapy), occlusal splint therapy alone, intraarticular injection (IAI) of hyaluronic acid (HA) or corticosteroid (CS), arthrocentesis with or without HA, CS and platelet-rich plasma (PRP), arthroscopy with or without HA and PRP, open joint surgery, and physiotherapy. Frequentist NMA was performed using STATA software. Studies meeting the inclusion criteria were divided according to the length of follow-up (short-term (≤5 months) and intermediate-term (≥6 months to 4 years) and type of TMJ arthrogenous disorders; internal derangement (ID) and TMJ osteoarthritis (OA). The standardized mean differences (SMD) in post-treatment pain reduction and maximum mouth opening (MMO) were analysed.ResultsThirty-six RCTs were identified that performed comparative outcome assessments for pain and 33 RCTs for MMO. At the short term (≤5 months), IAI-HA (SMD = −2.8, CI: −3.7 to −1.8) and IAI-CS (SMD = −2.11, CI: −2.9 to −1.2) (all very low quality evidence) achieved a substantially greater pain reduction than control/placebo.At intermediate term (≥6 months), a statistically significant decrease in posttreatment pain intensity was observed following Arthroscopy-PRP (SMD = −3.5, CI: −6.2 to −0.82), Arthrocentesis-PRP (SMD = −3.08, CI: −5.44 to −0.71), Arthroscopy-HA (SMD = −3.01, CI: −5.8 to −0.12), TMJ surgery (SMD = −3, CI: −5.7 to −0.28), IAI-HA (SMD = −2.9, CI: −4.9 to −1.09) (all very low quality evidence), Arthroscopy-alone (SMD = −2.6, CI: −5.1 to −0.07, low quality evidence) and Arthrocentesis-HA (SMD = −2.3, CI: −4.5 to −018, moderate-quality evidence) when compared to the control/placebo groups.Relative to MMO, the most effective treatments for short- and intermediate-term improvement were the arthroscopy procedures (PRP > HA > alone, all very low-quality evidence) followed by Arthrocentesis-PRP (very low-quality evidence) and Arthrocentesis-HA (moderate-quality evidence).The non-invasive procedures of occlusal splint therapy, physical therapy, conservative therapy, placebo/control provided significantly lower quality outcomes relative to pain and MMO.ConclusionThe results of the present meta-analysis support a paradigm shift in arthrogenous TMJ disorder treatment. There is a new evidence (though on a very low to moderate quality level) that minimally invasive procedures, particularly in combination with IAI of adjuvant pharmacological agents (PRP, HA or CS), are significantly more effective than conservative treatments for both pain reduction and improvement of MMO in both short (≤5 months) and intermediate term (6 months–4 years) periods. In contrast to traditional concepts mandating exhaustion of conservative treatment options, minimally invasive procedures, therefore, deserve to be implemented as efficient first-line treatments (e.g. IAIs and/or arthrocentesis) or should be considered rather early, i.e. as soon as patients do not show a clear benefit from an initial conservative treatment.     

Short-term treatment of a resilient appliance in TMD pain patients: a randomized controlled trial

Summary  To investigate the short-term efficacy of a resilient appliance in patients with temporomandibular disorders (TMD) suffering from pain, a randomized, controlled trial was performed in 80 recruited TMD pain patients. They were randomly allocated to one of two groups: treatment with a resilient appliance or treatment with a hard, palatal, non-occluding appliance. The primary treatment outcome measure was judged positive when patients' TMD pain at worst, according to the Visual Analog Scale (VAS), decreased by at least 30%. One additional treatment outcome was reduction of characteristic pain intensity. Number needed to treat was measured on the basis of primary treatment outcome at 10 weeks. At baseline, patient characteristics and TMD pain did not differ between the groups. There were no significant differences between groups regarding a 30% reduction in VAS-reported TMD pain at worst at 10 weeks' follow-up; 61% in the treatment group and 46% in the control group. After 6 and 10 weeks of treatment, CPI decreased in both groups. Number needed to treat was 9·1 for both the resilient and the control appliance therapy during 10 weeks. There was no statistically significant difference between the resilient appliance and the non-occluding control appliance in reducing TMD pain from a short-term perspective.     

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

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

Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint

This study intended in evaluating the effectiveness of exercise therapy in patients with craniomandibular disorders (CMD). Twenty consecutive patients suffering from CMD with anterior disc displacement without reduction consulting a CMD service were included in the study if they met following criteria: (i) pain in the temporomandibular region, (ii) reduced incisal edge clearance (<35 mm), (iii) magnet resonance imaging confirmed anterior disc displacement without reduction and (iv) evidence of postural dysfunction. All patients were assigned to a waiting list, serving as a no-treatment control period, according to a before-after trial. The treatment consisted of active and passive jaw movement exercises, correction of body posture and relaxation techniques. A total of 18 patients completed the study, no adverse effects occurred. Following main outcome measures were evaluated: (1) pain at rest (2) pain at stress (3) impairment (4) mouth opening at base-line, before and after treatment and at 6 month follow-up. As a result of treatment pain, impairment and mouth opening improved significantly more than during control period (paired samples t-test P < 0.05). After treatment four patients had no pain at all (chi-square: P < 0.05) and only seven patients revealed an impaired incisal edge clearance after treatment. (chi-square Test, P < 0.001). At follow up, seven patients had no pain and experienced no impairment. Exercise therapy seems to be useful in the treatment of anterior disc displacement without reduction.     

Reduction in parafunctional activity: a potential mechanism for the effectiveness of splint therapy

Interocclusal splints may be an effective modality in the management of temporomandibular disorders (TMD), but there is little evidence regarding the mechanism by which splints work. This study tested the hypothesis that pain reduction produced by splints is associated with reduction in parafunctional activity. In a two-group, single-blinded randomized clinical trial, patients diagnosed with myofascial pain received full coverage hard maxillary stabilization splints. Patients were instructed to maintain or avoid contact with the splint for the 6 weeks of active treatment. Patients who decreased the intensity of tooth contact were expected to show the greatest alleviation of pain, and those who maintained or increased contact were expected to report lesser reductions in pain. Experience-sampling methodology was used to collect data on pain and parafunctional behaviours at pre-treatment and during the final week of treatment. Patients were reminded approximately every 2 h by pagers to maintain/avoid contact with the splint. The amount of change in intensity of tooth contact accounted for a significant proportion of the variance in pain change scores. Patients who reduced tooth contact intensity the most reported greater relief from pain. Splints may produce therapeutic effects by reducing parafunctional activities associated with TMD pain.     

Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials

There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE^®, Cochrane, Web of Science, SciELO and EMBASE^™ electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate‐to‐high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance.