Outcomes of physical therapy in patients with temporomandibular disorder: a retrospective review

Temporomandibular disorder (TMD) encompasses a spectrum of disorders that are associated with pain in the temporomandibular joint (TMJ) and surrounding musculature. Current research shows that conservative physical therapy is beneficial in the management of the disorder. This study further explores if physical therapy is an effective approach to treating patients with TMJ disorders. Our objectives were to determine the effect of conservative physical therapy interventions on pain, maximal mouth opening, and TMJ disability index for patients with TMD. Medical records from 2013-2018 were retrospectively reviewed to identify patients and obtain demographic, baseline, and short-term outcomes of maximal mouth opening (MMO), pain, and temporomandibular disability index (TDI). A total of 100 patients were included. Significant changes were noted in MMO, pain rating, and TDI from initial evaluation to discharge from physical therapy. Sex, age, and weight did not affect the outcomes. There was also no correlation between the number of visits attended and change in MMO. Patients treated conservatively did show improvements in short term outcomes (MMO, pain rating, and TDI). These changes were statistically significant, indicating that conservative therapy may be a beneficial treatment option for patients with TMJ dysfunction. Future studies assessing the long-term outcomes of TMJ patients treated conservatively would determine if this treatment is beneficial in the long-term. In addition, researching the effectiveness of specific interventions for TMJ patients, and if certain TMJ disorders are more responsive to conservative care than others would be valuable in providing information on the effectiveness of conservative treatment in this patient population.     

自身免疫性疾病累及颞下颌关节的15例病例临床分析及文献回顾

目的 通过回顾分析,总结自身免疫性疾病导致颞下颌关节病变的临床和影像学特征,为早期明确诊断提供参考。方法 收集2014年12月至2021年6月于上海交通大学附属第九人民医院口腔外科就诊的15例自身免疫性疾病伴发颞下颌关节病变患者的病例资料,结合280例以往文献报道的病例分析其临床表现、影像学表现和治疗方法。结果 本文收集的15例患者中80%患者存在自身免疫性疾病病史,张口受限是患者最常见的主诉,其次为耳前疼痛。影像学检查可见无明显创伤诱因的关节上下腔积液、关节盘中带穿孔、无盘移位的髁突扁平状吸收、双侧囊内纤维性或骨性强直等表现。部分患者经抗风湿药物治疗疗效较好,4例进行了关节置换术,疗效稳定。结论 自身免疫性疾病所致的颞下颌关节病变患者在临床表现、影像学表现和治疗方式上均有特殊之处,尽早明确临床诊断以指导治疗方案的选择是必要的。     

Efficacy of Prolotherapy in Temporomandibular Joint Disorders: An Exploratory Study

IntroductionTemporomandibular joint (TMJ) disorders can be treated by both conservative and surgical approaches. Conservative interventions with predictable benefits can be considered as first-line treatment for such disorders. Dextrose prolotherapy is one of the most promising approaches in the management of TMDs, especially in refractory cases where other conservative management has failed.AimTo study the efficacy of prolotherapy and to establish it as an effective procedure in patients with TMJ disorders, to provide long-term solution to chronic TMJ pain and dysfunctions.Patients and MethodsWe conducted a study on 25 patients suffering from various TMJ disorders who were treated with prolotherapy, the solution consisting of 1 part of 50% dextrose (0.75 ml); 2 parts of lidocaine (1.5 ml); and 1 part of warm saline (0.75 ml). The standard programme is to repeat the injections three times, at 2-week interval, which totals four injection appointments over 6 weeks with 3-month follow-up.ResultsThere was appreciable reduction in tenderness in TMJ and masticatory muscles with significant improvement in mouth opening. The effect of the treatment in improving clicking and deviation of TMJ was found to be statistically significant (P < 0.05). There were no permanent complications.ConclusionOur study concluded that prolotherapy is an effective therapeutic modality that reduces TMJ pain, improves joint stability and range of motion in a majority of patients. It can be a first-line treatment option as it is safe, economical and an easy procedure associated with minimal morbidity.     

咬合创伤对颞颌关节软组织P物质样免疫反应的影响

为了探讨咬合创伤在颅颌紊乱症发生及发展中的生化机制，作者首次运用免疫组化技术观察小型猪正常时颞颌关节（ＴＭＪ）软组织Ｐ物质（ＳＰ）样免疫阳性反应的分布及其在咬合创伤时的反应变化。结果显示，除关节盘中带中部外，ＴＭＪ软组织各部均有ＳＰ样阳性反应分布，其中以关节盘周围为多，滑膜表层较少。咬合创伤时ＴＭＪ软组织中ＳＰ样免疫阳性反应增强，盘周附着组织中最为显著，滑膜组织也较明显。去除咬合创伤后ＳＰ样阳性反应明显减弱。提示盘周附着和滑膜组织对咬合创伤较敏感，由此引起的ＴＭＪ炎症和疼痛有ＳＰ的参与机制。     

Revision temporomandibular joint arthroplasty for the treatment of acquired metal allergy and review of the literature

The purpose of this study was to examine the outcomes of patients who received revision temporomandibular joint (TMJ) arthroplasty for the treatment of acquired metal allergy. It was hypothesized that subjects would have significant improvements in pain, swelling, and function. Patients who underwent TMJ revision due to nickel allergy were identified retrospectively. Outcomes documented included the presence or absence of facial erythema and facial swelling. Maximum incisal opening was also measured. Additional outcomes collected included age at initial surgery, initial TMJ device type, presenting symptoms, and TMJ device used for surgical revision. Four patients were identified with a nickel allergy to their TMJ prosthesis (containing nickel). All subjects experienced pain and swelling as their primary symptoms prior to the revision, with two subjects showing dermatological symptoms of overlying erythema. The four female subjects underwent exchange of their previously implanted prosthesis with a titanium alloy prosthesis. Postoperatively, all subjects showed improvements in pain score, resolution of swelling and erythema, and improvements in maximum incisal opening. This small case series suggests that revision TMJ arthroplasty with a titanium alloy prosthesis is a potential treatment for acquired metal allergy from traditional TMJ prosthesis implantation.     

Physiotherapy as an adjuvant therapy for treatment of TMJ disorders

Physiotherapy has long been used to cure joint and muscle diseases. It has also been used to treat various diseases without inflicting mental trauma or the pain of surgery. This adjunctive therapeutic modality is widely used for patients with orofacial disorders, especially in the prevention or treatment of temporomandibular joint (TMJ) disorder, hypomobility, or ankylosis. Physiotherapy has a particular importance in the treatment of TMJ disorders such as myofascial pain and internal derangement. This review article highlights the importance of physiotherapy as an emerging adjuvant therapy in the treatment of TMJ disorders.     

A new, noninvasive approach for successfully treating the pain and inflammation of TMJ disorders

This article introduces a new topical gel and method for rapidly relieving temporomandibular joint (TMJ), muscles of mastication, and myofacial pain while uniquely inhibiting the associated destructive chronic inflammation. The gel (composed of 18% potassium complex, 10% dimethylisosorbide, and 72% aqueous hydroxyethyl cellulose gel) was applied and gently rubbed onto the facial skin over the painful TMJs, muscles of mastication, and myofacial areas. The gel was applied as soon as clinicians identified the TMJ disorder, as the authors have found that the gel routinely and predictably provides rapid pain relief and patient comfort and speeds restoration of the jaw's functional abilities, usually within 5 minutes after it is applied. The relief is attributable to the combined ability of potassium and dimethylisosorbide to inhibit inflammation and pain. These dynamic results have led the authors to recommend that the gel be applied as a first-step procedure before trying to definitively diagnose and treat the cause(s) of the patients' pain and dysfunction. Once the pain had been eliminated as a complicating factor, a diagnosis and treatment plan concerning the jaw's biomechanical problems may be identified and dealt with. The ability to remove pain and inflammation as a first measure before making a definitive diagnosis and treatment plan minimizes patient anxiety, depression, and psychological concerns. Subsequent diagnosis and treatment of the biomechanical disorder(s) related to TMJ are then more easily and effectively accomplished.     

Outcomes of open temporomandibular joint surgery following failure to improve after arthroscopy: is there an algorithm for success?

We reviewed the results of one surgeon's experience of open surgical management of the temporomandibular joint (TMJ) in patients who fail to respond to arthroscopy and aimed to identify groups of patients that may or may not benefit from the intervention. Over a 7-year period (2005–2012) we retrospectively collected data from the medical notes of patients who underwent discectomy, disc plication, eminectomy, eminoplasty, and adhesiolysis, according to the clinical findings for joint pain, restriction, and locking. A total of 22 patients (71%) reported improvement in pain score and 19 (61%) reported an improvement in mouth opening 12 months postoperatively. Overall, 12 patients (39%) ultimately needed TMJ replacement. This group included 5/6 patients in Wilkes’ stage IV and 6/15 in stage V, 5/7 patients with a preoperative pain score of 90–100, and half of those with preoperative mouth opening of 20–29 mm (7/14). Open surgical management of the TMJ can benefit patients despite the previous failure of arthroscopy to manage pain, restriction, and locking. Arthroscopy seems to reduce the percentage of patients that need open TMJ surgery, but also the success of subsequent operations compared with previous studies. TMJ replacement is increasingly being done successfully to treat end-stage disease. These results may be used when obtaining a patient's consent for open TMJ surgery, particularly if they are in the groups considered to have a high risk of subsequently requiring a replacement joint.     

High resolution ultrasound investigation of the temporomandibular joint in patients with chronic polyarthritis

40 patients with chronic polyarthritis were investigated prospectively. The TMJ was investigated to detect clicking, crepitation, and pain. High resolution ultrasound (HR-US) assessed destructive changes, effusion, and disc dislocation. The results of the clinical investigation and the HR-US investigation were compared using the χ² test. The statistical calculation of the correlation between the HR-US results and the clinical TMJ investigation by the χ² test showed a significant correlation between TMJ sounds, destructive changes and disc dislocation. A significant correlation between TMJ joint effusion, TMJ pathology and TMJ pain was detected using the χ² test. Pain on palpation of the masseter and temporal muscle correlated significantly with TMJ effusion. There was significant correlation between TMD and the HR-US diagnosis of destructive changes and effusion. The significant correlation between TMJ effusion and actual TMJ pain and TMJ pain on palpation shows the ability of HR-US to detect acute TMJ affection with high significance. There was a significant correlation between effusion and pain on palpation of the masticatory muscles, which could be interpreted as the ability of HR-US to determine acute TMD. That any TMD correlated significantly with destructive changes and TMJ effusion suggests that HR-US could detect chronic and acute TMD.     

Chondroma of the mandibular condyle-relapse of a rare benign chondroid tumour after 5 years' follow-up: case report

Chondroma of the mandibular condyle is rare and its signs and symptoms can mimic those of patients with more common disorders of facial asymmetry or dysfunction of the temporomandibular joint (TMJ). We report a case of chondroma of the mandibular condyle that presented as temporomandibular pain with malocclusion, and which relapsed 5 years after the initial treatment. To our knowledge only 7 cases of chondroma of the mandibular condyle have been reported in the last 70 years. This case is the eighth.     

Topical review: new insights into the pathology and diagnosis of disorders of the temporomandibular joint

The collection of conditions affecting the temporomandibular joint (TMJ) and masticatory muscles, the so-called temporomandibular disorders, can be classified according to the Research Diagnostic Criteria for Temporomandibular Disorders. Of the 3 subgroups--muscle disorders (Group I); disc displacements (Group II); and arthralgia, arthritis, and arthrosis (Group III)--the muscle disorders are most frequently seen in community samples; Group II and Group III diagnoses are less prevalent. This may explain the relative scarcity of studies involving intracapsular TMJ disorders. In this review, new insights into the functional anatomy, imaging, and pathology of disorders of the TMJ are presented. Studies of TMJ dynamics may provide insight into the functional anatomy of the TMJ and thereby into the consequences of Group II and Group III disorders. The clinical use of imaging modalities such as computed tomography and magnetic resonance imaging for the TMJ and related structures remains controversial. Nevertheless, imaging is regularly used in the diagnosis of some Group II and Group III disorders. Magnetic resonance imaging may be of use not only for the visualization of disc displacements but also for the study of bone mineral density of the condyle. Cytokines such as interleukin-1 (IL-1) and tumor necrosis factor alpha (TNFalpha) play an important role in TMJ pathology. For example, IL-1beta, which has been associated with TMJ pain, hyperalgesia, and anterior bite opening, is mostly absent in the synovial fluid of healthy joints. Since both IL-1 and TNFalpha are involved in the development of chronic pain and joint destruction, they may be the targets for specific treatments. While the advances reviewed in this paper are significant, multidisciplinary efforts and formation of international research collaborations will be necessary to continue advancement in the understanding of TMJ pathology and diagnosis.     

Chewing ability as a parameter for evaluating the disability of patients with temporomandibular disorders

Restoration of chewing ability is an important aspect of the treatment for temporomandibular disorders (TMDs). However, too little attention has been paid to it. We have used a questionnaire to evaluate and score the chewing ability of TMD patients. The questionnaire includes 19 kinds of food and a chewing task. The patient was asked if she/he experiences difficulty in enjoying eating. The aim of this study was to evaluate correlations between score of chewing ability (SCA) and other symptoms/signs of TMD. Four hundred and seventy-three consecutive TMD patients were evaluated for SCA and other symptoms/signs including temporomandibular joint (TMJ) pain, TMJ and muscle tenderness, TMJ noise (clicking and crepitus), and maximum mouth opening. The relationship between SCA and other symptoms/signs were analysed by multiple regression analysis. Score of chewing ability correlated significantly with TMJ pain and mouth opening capacity but not with TMJ noise and muscle tenderness. Age was a background factor but sex was not. The result of this study suggests that SCA correlated with dysfunction of the TMD patients. This method could be used to evaluate the ability of chewing in assessment of TMD.     

Will they fit? Determinants of the adaptability of stock TMJ prostheses where custom TMJ prostheses were utilized

Currently only two alloplastic temporomandibular joint (TMJ) total joint replacement (TJR) systems are available in the United States. The aim of this study was to define variables that determine whether a Biomet stock prosthesis could have been used to reconstruct a TMJ previously reconstructed with a TMJ Concepts patient-fitted prosthesis. All of the TMJ Concepts prostheses placed between 2010 and 2018 at the University of Texas – Health at San Antonio were analyzed retrospectively. There were 128 cases (241 joints) with intact stereolithographic models analyzed for successful adaptation of the Biomet stock TMJ prosthesis. Anatomical, demographic, etiological, and perioperative data were gathered for each joint to investigate possible causes of failure of stock adaptation. The majority of joints, 74% (178/241), could have had a stock prosthesis adapt. All joints with ≥40 mm gap arthroplasty failed stock prosthesis adaptation. Only 50% (32/64) of the joints with at least one previous open TMJ surgery and 60% (58/96) of the joints with concomitant orthognathic surgery could have had a stock TMJ prosthesis. The stock prosthesis could not be adapted for any of the patients requiring TMJ replacement for congenital disorders or those requiring TMJ salvage. Overall, the majority of cases treated with a patient-specific TMJ TJR could have been treated with a stock prosthesis.     

A cohort study of patients with juvenile idiopathic arthritis and arthritis of the temporomandibular joint: outcome of arthrocentesis with and without the use of steroids

The purpose of this study was to evaluate the effects of intra-articular temporomandibular joint (TMJ) treatment in patients with juvenile idiopathic arthritis (JIA). The inclusion criteria were met by 21 patients (38 joints). Joints were randomly selected for either arthrocentesis alone (n = 17) or arthrocentesis with the additional use of triamcinolone hexacetonide (n = 21) using a closed single-needle system. Measurements of pain and function were performed at baseline and at follow-up after 3 and 8 months. Pain on opening and lateral excursion improved significantly after injections. Pain decreased significantly from baseline to first and second control on a visual analogue scale (VAS) for overall pain (49–18–8) and overall function (41–19–4). Significant improvement was recorded for pain on palpation of muscles and joints. There was no statistically significant difference between the treatment modalities, with or without glucocorticoid injection. Arthrocentesis in the TMJ treatment of patients with JIA may be beneficial and steroids had no additional effect. Further studies are needed to evaluate the long-term effects on the TMJ structures and on condylar growth from arthrocentesis and intra-articular steroid injections.     

The use of bone scintigraphy in temporomandibular joint disorders

INTRODUCTION: The use of bone scintigraphy (bone scan) in the diagnosis of temporomandibular joint (TMJ) disease has been infrequent, as compared with traditional radiographic techniques. Bone scans have the potential to detect active bone remodeling whereas corresponding radiographs may be normal or document past structural change in the joint. Traditional radiographic findings and relevant clinical signs and symptoms correlated with bone scans may aid in the diagnosis of TMJ disease and possibly affect treatment and prognosis of individual cases. The use of bone scans as an additional tool in diagnosing TMJ disease was assessed in this series of patients. METHODS: Thirty consecutive subjects with TMJ tenderness were selected for bone scintigraphy using technetium diphosphonate 99 mTc and single photon emission computerized tomography. These subjects received bone scans as well as other selected imaging modalities for diagnostic purposes. RESULTS AND DISCUSSION: The findings on bone scan were evaluated and a change in preliminary clinical diagnosis or treatment was made in 60% of cases because of the findings on bone scintigraphy. Bone scintigraphy may be valuable to assess progress of TMJ inflammation or remodeling, and may affect diagnosis and treatment of patients with TMJ tenderness.     

Outcomes of office-based temporomandibular joint arthroscopy: a 5-year retrospective study

Temporomandibular joint (TMJ) arthroscopy is a minimally invasive surgical approach for intra-articular TMJ diseases. Office-based arthroscopy using the smallest TMJ scope allows for good visualization, as well as the ability to lavage the joint in an office setting. This study aimed to assess the efficacy of an office-based TMJ arthroscopic technique. A retrospective evaluation of 363 patients with a TMJ disorder was performed. These patients underwent office-based arthroscopy using the OnPoint 1.2 mm Scope System (Biomet Microfixation, Jacksonville, FL, USA) in Florida, USA, from July 2007. The following outcomes of the procedure were assessed: improvement in painless range of mandibular motion, pain on loading, and functional jaw pain; these were evaluated using a visual analog scale (VAS) over an average follow-up period of 263.81 ± 142.1 days. The statistical analysis was performed using IBM SPSS Statistics version 20. Statistically significant improvements in TMJ pain and function, and other variables (P = 0.001) were shown following TMJ arthroscopic lysis and lavage. Office-based arthroscopy using the OnPoint System was demonstrated to be a safe and efficient procedure for the treatment of patients with TMJ disorders as the first level of the algorithm of care.     

Destructive psoriatic arthritis of the temporomandibular joint: a clinical case,an overview of the pathophysiology and its differential diagnoses

Abstract

Background Clinical assessments and uniplanar images in temporomandibular disorders are not always entirely reliable. This predicament is especially important when clinicians need to determine the nature of temporomandibular joint disease, particularly when clinical features are not helpful in determining the diagnosis.

Clinical presentation A 63-year-old female patient presented with mild pain in her right TMJ. During routine imaging exams, a destructive monoarticular arthritis was noticed, producing multiple erosions of the mandibular and temporal condyles. In addition, attrition of the ceiling of the glenoid fossa was observed, generating a communication with the endocranium. Only the presumptive biological behavior revealed on TMJ imaging and the appearance of the psoriatic plaques later during follow-up helped the authors to narrow the differential diagnosis.

Conclusion The clinical case presented illustrates the difficulties in diagnosing an erosive, seronegative TMJ destruction, suggestive of a systemic arthritis.     

Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation

Temporomandibular joint (TMJ) dislocation is an excessive forward movement of the condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position. This study was conducted to assess autologous blood injection to the TMJ for the treatment of chronic recurrent TMJ dislocation. Fifteen patients with bilateral chronic recurrent condylar dislocation were included in the study. Bilateral TMJ arthrocentesis was performed on each patient, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. Preoperative and postoperative assessment included a thorough history and physical examination to determine the maximal mouth opening, presence of pain and sounds, frequency of luxation, recurrence rate, and presence of facial nerve paralysis. Eighty percent of the subjects (12 patients) had a successful outcome with no further episodes of dislocation and required no further treatment at their 1-year follow-up, whereas three patients had recurrent dislocation as early as 2 weeks after treatment. Autologous blood injection is a safe, simple, and cost-effective treatment for chronic recurrent TMJ dislocation.     

咬合抬高对颞颌关节结构及症状的影响

目的：探讨深覆胎或牙齿重度磨耗病人咬合抬高后对颞颌关节结构及症状的影响.方法：随机选取近两年在我院口腔修复科就诊的深覆胎或重度磨耗患者36例为受试对象,其中男性21例,女性15例,年龄36-53岁,治疗前后常规进行颞颌关节的临床检查,拍摄双侧颞颌关节开闭口位核磁共振并对关节情况进行分析.结果：36例患者的72个关节中,治疗前可复性盘前移21个关节,治疗后10个,差异有统计学意义（P＜0.05）.不可复性盘前移14例,治疗后13例,差异无统计学意义（P＞0.05）.治疗前关节弹响13例,治疗后9例,差异无统计学意义（P＞0.05）.治疗前关节区轻度疼痛12例,治疗后4例,差异有统计学意义（P＜0.05）.治疗前关节区中度疼痛8例,治疗后7例,差异无统计学意义（P＞0.05）.治疗前关节区重度疼痛2例,治疗后2例,差异无统计学意义（P＞0.05）.结论：咬合抬高对于颞颌关节可复性关节盘前移位和轻度关节区疼痛有一定治疗作用,对于不可复性盘前移,弹响及中,重度疼痛无缓解作用.     

Neuroendocrine, immune, and local responses related to temporomandibular disorders

Orofacial pain frequently originates from pathologic conditions in the masticatory muscles or temporomandibular joints (TMJs). The mediators and mechanisms that monitor pain and inflammation, centrally or peripherally, are of great interest in the search for new treatment modalities. The neuropeptides substance P (SP), calcitonin gene-related peptide (CGRP), and neuropeptide Y (NPY) have all been found at high levels in the synovial fluid of arthritic TMJs in association with spontaneous pain, while serotonin (5-HT) has been found in association with hyperalgesia/allodynia of the TMJ. Interleukin-1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF alpha) have been found in arthritic TMJs, but not in healthy TMJs, in association with hyperalgesia/allodynia of the TMJ as well as spontaneous pain. Anterior open bite, which may be a clinical sign of TMJ destruction, has been found in association with high levels of CGRP, NPY, and IL-1 beta in the synovial fluid of the TMJ. Interleukin-1 beta has also been related to radiographic signs of joint destruction. Prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) are both present in the arthritic TMJ, and PGE2 has been shown to be associated with hyperalgesia/allodynia of the TMJ. Very little is known about pain and inflammatory mediators in muscles. However, we know that 5-HT and PGE2 are involved in the development of pain and hyperalgesia/allodynia of the masseter muscle in patients with fibromyalgia, whereas local myalgia (myofascial pain) seems to be modulated by other, as yet unknown mediators. Interaction between the peripheral nervous system (sensory and sympathetic nerves), the immune system, and local cells is probably of great importance for the modulation of pain and inflammation in the TMJ and orofacial musculature.