The treatment of painful temporomandibular joint clicking with oral splints: a randomized clinical trial

BACKGROUND: The authors compared the efficacy of bilateral balanced and canine guidance (occlusal) splints in the treatment of temporomandibular joint (TMJ) pain in subjects who experienced joint clicking with a nonoccluding splint in a double-blind, controlled randomized clinical trial. METHODS: The authors randomly assigned 57 people with signs of disk displacement and TMJ pain into three groups according to the type of splint: bilateral balanced, canine guidance and nonoccluding. The authors followed the groups for six months using analysis of a visual analog scale (VAS), palpation of the TMJ and masticatory muscles, mandibular movements and joint sounds. They used repeated analysis of variance and a chi(2) test to test the hypothesis. RESULTS: The type of guidance used did not influence the pain reduction, yet both occlusal splints were superior to the nonoccluding splint, on the basis of the VAS. Despite similar outcomes in relation to opening, left lateral and protrusive movements, TMJ and muscle pain on palpation, subjects who used the occlusal splints had improved clinical outcomes. The frequency of joint noises decreased over time, with no significant differences among groups. Subjects in the groups using the occlusal splints reported more comfort. CONCLUSION: The type of lateral guidance did not influence the subjects' improvement. All of the subjects had a general improvement on the VAS, though subjects in the occlusal splint groups had better results that did subjects in the nonoccluding splint group.     

Long-term efficacy of resilient appliance therapy in TMD pain patients: a randomised, controlled trial

The aim was to investigate long-term efficacy of a resilient appliance in patients with pain due to temporomandibular disorders (TMD). A randomised, 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 was judged positive when patients' characteristic pain intensity decreased by at least 30%. Additional treatment outcomes were physical functioning, emotional functioning and headache. At the 12-month follow-up 50% of the patients in the treatment group and 42% in the control group had a 30% reduction of characteristic pain intensity, when calculated in an intent-to-treat analysis. Jaw function improved in both groups at the 6- and 12-month follow-up. Emotional functioning improved in both groups at the 6-month follow-up; an improvement concerning grade of depression was found in the control group at 12 months. Headache decreased in both groups at both follow-ups. There were no statistically significant differences found regarding primary and additional outcomes between groups at the 6- and 12-months follow-up. There was no statistically significant difference between the resilient appliance and the non-occluding control appliance in reducing TMD pain, physical functioning, emotional functioning and headache in a 12 months perspective.     

Comparison of three different types of splints and templates for maxilla repositioning in bimaxillary orthognathic surgery: a randomized controlled trial

The selection and implementation of a plan for maxillary surgery is of the utmost importance in achieving the desired outcome for the patient undergoing two-jaw orthognathic surgery. Some splint-based and splintless methods, accompanied by computer-assisted techniques, are helpful in improving surgical plan implementation. However, randomized controlled trials focused on this procedure are lacking. This study included 61 patients who underwent bimaxillary surgeries. The patients were randomly assigned to a conventional resin occlusal splint (CROS) group, a digital occlusal splint (DOS) group, or a digital templates (DT) group, in a 1:1:1 ratio. The mean linear distance between the planned and actual postoperative positions of eight selected points on the surfaces of the maxillary teeth was selected as the outcome measure. The distance was significantly smaller in the DT group (1.17 ± 0.66 mm) when compared to both the CROS group (2.55 ± 0.95 mm, P < 0.05) and DOS group (2.15 ± 1.12 mm, P < 0.05). However, the difference between the CROS group and DOS group was not statistically significant. These findings indicate that using digital templates results in the best performance in transferring the surgical plan to the operation environment as compared to the other two types of splints. This suggests that the application of digital templates could provide a reliable treatment option.     

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.     

The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: a randomized controlled trial

BACKGROUND: Treatment recommendations for patients with painful temporomandibular disorders (TMDs) range from conservative treatments such as physiotherapy to aggressive and irreversible treatments such as restorative reconstruction and joint surgery. METHODS: The authors randomized 200 subjects diagnosed with TMD into three groups: usual conservative, dentist-prescribed self-care treatment without any intraoral splint appliance (UT); UT plus a conventional flat-plane hard acrylic splint (HS); and UT plus a soft vinyl (a low-cost athletic mouth guard) splint (SS). Subjects completed questionnaires and clinical examinations at three, six and 12 months. RESULTS: The authors observed no significant differences among the groups in TMD-related pain levels or other common signs and symptoms of TMD at baseline (BL) or at any follow-up. The changes from BL were comparable for all three groups. The authors did not note any significant differences at any follow-up for compliance with study protocols or for occurrences of adverse effects from either splint type. For HS versus SS, there were significant differences in rates of splint use, but these differences were not accompanied by differences in either self-reported symptoms or in clinical findings. CONCLUSIONS: All patients improved over time, and traditional splint therapy offered no benefit over the SS splint therapy. Neither splint therapy provided a greater benefit than did self-care treatment without splint therapy. CLINICAL IMPLICATIONS: These findings suggest that clinicians who treat patients with TMD should consider prescribing low-cost nonsplint self-care therapy for most patients.     

Comparison of three treatment options for painful temporomandibular joint clicking

A randomized clinical trial was performed to evaluate the efficacy of three treatment options, including anterior positioning splint therapy, physical therapy, and physical therapy in addition to splint therapy, in terms of treatment outcome, in patients with painful temporomandibular joint clicking. Sixty patients suffering from acute pain and dysfunction were divided randomly into three treatment groups. Twenty patients underwent anterior positioning splint therapy (group I), 20 patients received solely physical therapy (group II), and 20 subjects received physical treatment in addition to splinting (group III). All patients were examined before and after the treatment using a visual analogue scale (VAS) and digital palpation of joint sounds. The data were analyzed using the Kruskal-Wallis, one-way ANOVA and Tukey tests at a significance level of P < 0.05. In comparison with the baseline, subjective pain was decreased significantly (P < 0.05) in all three groups. A significant difference was observed between groups I and II (P <0.05), whereas no significant difference was detected between groups II and III. Six patients in group III did not continue the treatment after physical therapy. The numbers of pain-free patients were 12 in group I, 5 in group II and 9 in group III. We observed a reduction in the frequency of joint sounds across the entire sample (P < 0.05). Anterior positioning splint therapy appears to be the best treatment method for reduction of pain and joint sounds in patients with TMD, compared with the other two methods studied.     

Validation and improvement of a predictive model for treatment outcome in patients with temporomandibular disorders

Objective. To examine whether it was possible to improve individual prediction of treatment outcome in patients with temporomandibular disorders (TMD) through continuous quality improvement registrations and implementation of changes in clinical routines. Material and methods. All 5777 patients referred to a specialist clinic for stomatognathic physiology; 2187 TMD patients started treatment. The patients were divided into Muscle or Mainly TMJ symptom groups. Actual treatment outcome was predicted as Good or Dubious based on patient history and clinical findings. The degree of improvement of initial symptoms was graded using a numeric rating scale 0–100. Improvement in initial complaints of 50% or more was judged as a clinically important difference (CID); 989 patients (76%) completed treatment 1992–1998 (Sample 1) and 769 (86%) treatment 1999–2004 (Sample 2). Results. For patients with Muscle symptoms in Sample 1, CID was reached by 90% of those predicted Good and by 56% of those predicted Dubious. In Sample 2, the figures were Good 93% and Dubious 57%. In subgroup Mainly TMJ symptoms, CID was reached by 94% of those predicted Good and by 88% if predicted Dubious in Sample 1. In Sample 2, the figures were the same for those predicted Good, i.e. 94%, and Dubious, 73%. Conclusion. Continuous quality improvement registrations and implementation of changes in clinical routines improved the ability to predict individually the actual treatment outcome between patients predicted Good or Dubious, respectively. Rheumatic disease turned out not to be a negative predictor for treatment outcome.     

Effects of exercise therapy on painful temporomandibular disorders

Temporomandibular disorders (TMD) are common chronic musculoskeletal pain conditions among orofacial pain. Painful TMD condition such as myalgia and arthralgia can be managed by exercise therapy. However, as it is hard to access actual effect of each modality that is included in an exercise therapy programme due to multiple choice of the management modality, their efficacy remains controversial. Therefore, this review focused on the effects of exercise therapy for the management of painful TMD. The aims of this review were to summarise the effects of exercise therapy for major symptoms of painful TMD and to establish a guideline for the management of painful TMD, resulting in higher quality and reliability of dental treatment. In this review, exercise modalities are clearly defined as follows: mobilisation exercise, muscle strengthening exercise (resistance training), coordination exercise and postural exercise. Furthermore, pain intensity and range of movements were focused as outcome parameters in this review. Mobilisation exercise including manual therapy, passive jaw mobilisation with oral appliances and voluntary jaw exercise appeared to be a promising option for painful TMD conditions such as myalgia and arthralgia. This review addressed not only the effects of exercise therapy on various clinical conditions of painful TMD shown in the past, but also an urgent need for consensus among dentists and clinicians in terms of the management of each condition, as well as terminology.     

Management of pain in TMD patients: Bio-oxidative ozone therapy versus occlusal splints

Objective: To compare the effects of bio-oxidative ozone application with occlusal splints in temporomandibular disorder (TMD) patients with pain.

Methods: Forty participants were selected after the diagnosis of TMD and randomly divided into two groups: ozone group (OG, n = 20) and occlusal splint group (OCSG, n = 20). Ozone was applied to patients three times per week, for a total of six sessions. Patients in the OCSG were instructed to use occlusal splints every night over a period of four weeks.

Results: Mandibular movements showed significant differences for the time factor in OG and OCSG. Pressure pain thresholds of the temporal and masseter muscles at follow-up were significantly higher in the OCSG group. Both treatments statistically decreased the visual analog scale (VAS) scores. However, no statistically significant difference was observed between groups after the application of treatments.

Discussion: Occlusal splint treatment is still the gold treatment modality for objective pain relief in patients with TMD pain.     

Management of painful temporomandibular joint clicking with different intraoral devices and counseling: a controlled study

Objective

The benefit of the use of some intraoral devices in arthrogenous temporomandibular disorders (TMD) patients is still unknown. This study assessed the effectiveness of the partial use of intraoral devices and counseling in the management of patients with disc displacement with reduction (DDWR) and arthralgia.

Materials and Methods

A total of 60 DDWR and arthralgia patients were randomly divided into three groups: group I (n=20) wore anterior repositioning occlusal splints (ARS); group II (n=20) wore the Nociceptive Trigeminal Inhibition Clenching Suppression System devices (NTI-tss); and group III (n=20) only received counseling for behavioral changes and self-care (the control group). The first two groups also received counseling. Follow-ups were performed after 2 weeks, 6 weeks and 3 months. In these sessions, patients were evaluated by means of a visual analogue scale, pressure pain threshold (PPT) of the temporomandibular joint (TMJ), maximum range of motion and TMJ sounds. Possible adverse effects were also recorded, such as discomfort while using the device and occlusal changes. The results were analyzed with ANOVA, Tukey’s and Fisher Exact Test, with a significance level of 5%.

Results

Groups I and II showed improvement in pain intensity at the first follow-up. This progress was recorded only after 3 months in Group III. Group II showed an increased in joint sounds frequency. The PPT values, mandibular range of motion and the number of occlusal contacts did not change significantly.

Conclusion

The simultaneous use of intraoral devices (partial time) plus behavioral modifications seems to produce a more rapid pain improvement in patients with painful DDWR. The use of NTI-tss could increase TMJ sounds. Although intraoral devices with additional counseling should be considered for the management of painful DDWR, dentists should be aware of the possible side effects of the intraoral device’s design.     

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.     

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。     

A systematic review and meta-analysis of randomized controlled trials comparing arthrocentesis with conservative management for painful temporomandibular joint disorder

The aim of this study was to determine whether arthrocentesis is superior to conservative treatment in the management of painful temporomandibular joint disorders with restricted opening. A systematic review was undertaken of prospective randomized controlled trials (RCT) comparing arthrocentesis to conservative management, identified in the MEDLINE and PubMed databases. Inclusion criteria included a 6-month follow-up, with clinical assessment of the patients and painful restricted mouth opening. Data extracted included pain measured on a visual analogue scale and maximum mouth opening measured in millimetres. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2 for RCTs, and a meta-analysis with the random-effects model was undertaken. Of 879 records retrieved, seven met the inclusion criteria; these RCTs reported the results at 6 months for 448 patients. One study had a low risk of bias, four studies had an uncertain risk, and two had a high risk of bias. In the meta-analysis, arthrocentesis was statistically superior to conservative management at 6 months for an increase in maximum mouth opening (1.12 mm, 95% confidence interval 0.45–1.78 mm; P = 0.001; I² = 87%) and borderline superior for pain reduction (−1.09 cm, 95% confidence interval −2.19 to 0.01 cm; P = 0.05; I² = 100%). However, these differences are unlikely to be clinically relevant.     

Role of psychosocial factors on treatment outcome of temporomandibular disorders

Objectives: The aim of this randomized controlled study was to investigate the effect of depressive and non-specific physical symptoms on treatment outcome of temporomandibular disorders (TMD).

Material and methods: Eighty TMD patients were randomly assigned to splint group (n?=?39) and control group (n?=?41). The patients were classified in terms of depressive and non-specific physical symptoms as normal, moderate or severe using Research Diagnostic Criteria for Temporomandibular Disorders Axis II protocol. The effect of depressive and non-specific physical symptoms on the intensity of facial pain, as measured with visual analogue scale (VAS) was estimated with linear mixed models. The patients’ subjective estimates of the effects of treatment and TMD symptom severity were inquired at 1-year follow-up.

Results: At baseline and during the follow-up there were no significant differences in VAS scores between patients in different Axis II subscales. According to the mixed linear regression, depressiveness or nonspecific physical symptoms separately were not significantly associated with the VAS during the study. The association of VAS with depressive (p?=?.073) and nonspecific physical symptoms (p?=?.088) approximated statistical significance. Patients with moderate or severe nonspecific physical symptoms (with pain items) at baseline had more frequently moderate, severe or intolerable TMD symptoms after the treatment compared to those who were classified in normal subgroup.

Conclusions: The present study gave some indication of a possible negative effect of depressive and nonspecific physical symptoms (with pain items) on TMD treatment response. However, the results should be regarded as preliminary, and further studies with larger sample size are needed to confirm the results.     

Factors associated with clinical decision-making in relation to treatment need for temporomandibular disorders

Objective. The aim of this study was to analyze dentist’s clinical decision-making related to treatment need for temporomandibular disorders (TMD) in an adult population. Materials and methods. The study population comprised 779 randomly selected 35, 50, 65 and 75 year old individuals living in the county of Västerbotten, Sweden. The participants filled out a questionnaire and were examined clinically according to a structured protocol. The four examiners (two men, two women) were experienced dentists and were calibrated before the start of the study. After examination they individually assessed the need of treatment owing to TMD. Results. In total, 15% of the study population was considered to have a treatment need owing to TMD. The highest estimate was noted for 35 and 50 years old women and the lowest for 65 and 75 years old men. Overall, 21% of the women and 8% of the men were considered to have a treatment need owing to TMD, with statistically significant differences between men and women for the 35 and 50 years old groups. Inter-individual variations in dentists’ decisions were observed. In a multivariate analysis, female gender, signs and symptoms of TMD pain, signs and symptoms of TMD dysfunction and smoking were associated with estimated treatment need. Conclusions. The prevalence of estimated treatment need owing to TMD was fairly high, but the dentists’ clinical decision-making process showed large inter-individual variability. The observation calls for further research on the factors affecting the decision-making process in care providers.     

Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

The purpose of this study was to clinically evaluate the efficacies of three treatment methods and to compare their outcomes in patients with painful disc displacement. The study group comprised 45 patients with unilateral temporomandibular disorders who fell into Axis I group II (with limited mouth opening) of the Research Diagnostic Criteria for Temporomandibular Disorders. Magnetic resonance imaging was used for definitive diagnosis. The patients were divided randomly into three groups according to the treatment method: splint therapy, splint therapy with ultrasound-guided arthrocentesis, and splint therapy with low-level laser therapy. Patients were followed up after treatment for 6 months. The groups were compared in terms of pain and functional jaw movements (unassisted mouth opening without pain, maximum unassisted mouth opening, and contralateral movements). At the end of treatment, functional jaw movements were significantly increased while pain values were significantly decreased in all groups (P < 0.05). Group 2 had a quicker improvement in terms of mouth opening scores at the end of the first month, and unassisted mouth opening without pain was found to be more than 35 millimetres in all groups at the end of 6 months. All treatment modalities showed effective results on pain and functional jaw movements in the treatment of temporomandibular disorders.     

Transcranial direct current stimulation and exercises for treatment of chronic temporomandibular disorders: a blind randomised‐controlled trial

To evaluate the effect of adding transcranial direct current stimulation (tDCS) to exercises for chronic pain, dysfunction and quality of life in subjects with temporomandibular disorders (TMD). Participants were selected based on the RDC/TMD criteria and assessed for pain intensity, pressure pain threshold over temporomandibular joint and cervical muscles and quality of life. After initial assessment, all individuals underwent a 4‐week protocol of exercises and manual therapy, together with active or sham primary motor cortex tDCS. Stimulation was delivered through sponge electrodes, with 2 mA amplitude, for 20 min daily, over the first 5 days of the trial. A total of 32 subjects (mean age 24·7 ± 6·8 years) participated in the evaluations and treatment protocol. Mean pain intensity pre‐treatment was 5·5 ± 1·4 for active tDCS group, and 6·3 ± 1·2 for sham tDCS. Both groups showed a decrease in pain intensity scores during the trial period (time factor – F_4·5,137·5 = 28·7, P < 0·001; group factor – F_1·0,30·0 = 7·7, P < 0·05). However, there were no differences between the groups regarding change in pain intensity (time*group interaction – F_4·5,137·5 = 1·5, P = 0·137). This result remained the same after 5 months (t‐test t = 0·29, P > 0·05). Pressure pain thresholds decrease and improvement in quality of life were also noticeable in both groups, but again without significant differences between them. Absolute benefit increase was 37·5% (CI 95%: ?15·9% to 90·9%), and number needed to treat was 2·66. This study suggests that there is no additional benefit in adding tDCS to exercises for the treatment of chronic TMD in young adults.     

Arthrocentesis as initial treatment for temporomandibular joint arthropathy: A randomized controlled trial

ObjectiveTo determine the effectiveness of arthrocentesis compared to conservative treatment as initial treatment with regard to temporomandibular joint pain and mandibular movement.Patients and methodsIn this randomized controlled trial, 80 patients with arthralgia of the TMJ (classified according to the Research Diagnostic Criteria for Temporomandibular Disorders) were randomly assigned to one of the two treatment groups. One group received arthrocentesis as initial treatment (n = 40), the other group received conventional treatment including soft diet, physical treatment and occlusal splint therapy (n = 40). Follow-up was after 3, 12 and 26 weeks post treatment. Prior to treatment, and at every follow-up assessment, pain intensity was measured (VAS 0–100 mm at rest, and VAS 0–100 mm during movement) and maximum mouth opening (MMO) (mm interincisor distance). Furthermore patients were asked to fill out several surveys concerning the impact of mandibular impairment on their daily life, and psychosocial aspects.ResultsAfter 26 weeks, the TMJ pain (mm VAS at rest, and mm VAS during movement) had declined comparably in both groups (arthrocentesis n = 36; conservative treatment n = 36) and MMO (mm interincisor distance) had slightly improved. GEE models showed significant differences between arthrocentesis as initial treatment and conservative treatment, indicating that the arthrocentesis group improved more rapidly with regard to TMJ pain (VAS at rest p = 0.008; regression coefficient β = −8.90 (95% confidence interval −15.50, −2.31), VAS during movement p = 0.003; regression coefficient β = −10.76 (95% confidence interval −17.75, −3.77)) and MMO (p = 0.045; regression coefficient β = −2.70 (95% confidence interval −5.35, −0.06)) compared to conservative treatment.ConclusionsArthrocentesis as initial treatment reduces pain and functional impairment more rapidly compared to conservative treatment. However, after 26 weeks, both treatment modalities achieved comparable outcomes.Trial registration numberwww.trialregister.nl: NTR1505.