Counselling and self‐management therapies for temporomandibular disorders: a systematic review

The aim of this review was to investigate the effectiveness of counselling and other self‐management‐based therapies on muscle and temporomandibular joint (TMJ) pain relief and increasing the functional abilities of patients with temporomandibular disorders (TMD). A systematic literature review was conducted by three independent reviewers and included articles published up to 2012. PubMed and Cochrane Library electronic databases were used in addition to hand‐searching to assess clinical outcomes for counselling and self‐management approaches for TMD treatment. The review yielded 581 records that were narrowed down to 7. All included studies were classified as blind‐randomized controlled clinical trials. The selected articles analysed revealed that counselling was able to improve tenderness upon masticatory muscle palpation and maximum mouth opening with and without pain in patients with TMD, with similar results to those of interocclusal appliances approaches. Thus, counselling‐ and self‐management‐based therapies could be considered a conservative low‐cost and beneficial treatment alternative for treating TMD to potentially improve psychological domains and remove harmful behaviours for the control of the signs and symptoms of TMD.     

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.     

张口训练对伴张口受限的颞下颌关节紊乱病患者最大开口度恢复的短期影响

目的研究主动与被动结合的张口训练对伴张口受限的患者透明质酸钠关节腔注射治疗后短期最大开口度（MMO）恢复的影响。 方法收集2017—2018年就诊于广州医科大学附属口腔医院颞下颌关节科伴张口受限的颞下颌关节紊乱病（TMD）患者49例，所有患者均接受透明质酸钠关节腔注射治疗。其中25例患者术后接受常规健康宣教方案（对照组），另外24例患者术后在常规健康宣教方案基础上结合主动、被动张口训练治疗（张口训练组），并使用t检验、卡方检验、线性回归模型对两组患者MMO恢复情况进行比较。 结果对照组患者在术后2周MMO较张口训练组小3 mm，差异有统计学意义（t = 2.049，P = 0.046），对照组患者在术后4周MMO较张口训练组小4 mm，差异有统计学意义（t = 3.128，P = 0.003）。 结论张口训练对TMD患者术后张口度恢复有积极作用，并可在4周内体现出辅助MMO恢复的优势。     

The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders

Because the concept of whiplash as a causative factor for temporomandibular disorders (TMD) is highly controversial, we decided to do a retrospective analysis of patients treated in our office who had sustained whiplash injuries and were treated for cervical and temporomandibular disorders. The records of 300 patients with TMD preceded by a motor vehicle accident were examined retrospectively. The most common presenting symptoms, in order, were: jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe temporomandibular joint (TMJ) clicking. The most common TMD diagnoses were: masseter trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw muscle hyperactivity, and advanced TMJ disk derangement. Based primarily on the physical examination, we concluded that the TMJ and surrounding musculature should be examined similarly to other joints, with no preconceived notion that TMD pathology after whiplash is unlikely.     

An assessment of the usefulness of Kinesiograph as an aid in the diagnosis of TMD: a review of Manfredini et al.'s studies

Aim:

Performing a literature review of publications by Dr. Manfredini et al. related to their temporomandibular joint (TMJ) injection therapy outcome with conclusions on the clinical utility of computerized measurement devices used in the management of temporomandibular disorders (TMDs). In addition, reviewing their published opinion on an occlusion: TMD versus a biopsychosocial paradigm for TMD. Manfredini et al. authored an article published in the Journal of the American Dental Association (JADA) 2013, “An Assessment of the usefulness of jaw kinesiography in monitoring temporomandibular disorders,” the most recent of 12 articles. In all studies, subjects received TMJ injections with an objective measurement outcome criterion; increased maximum mouth opening (MMO) and subjective symptom improvement of pain and chewing function. In the 2013 JADA article, the Mandibular Kinesiograph, referred to as KG, measured MMO before and after therapy. In 11 prior articles, all subject groups with limited mouth opening exhibited very significant increased MMO post-treatment, documenting treatment success using the same 2013 protocol. The 2013 study showed a 1·1 mm improved MMO, described as insignificant. The authors did not critique or explain the aberrant, skewed 2013 outcome data contrasted with their prior studies, which showed overwhelmingly significant increased MMO. Instead, they concluded that the MMO recording device was clinically useless. This motivated a literature review of the authors’ TMD publications.

Conclusion:

The publications by Manfredini et al. recognized proponents of the psychosocial model of TMD, including the 2013 article, appear to be part of a campaign denying an occlusion: TMD relationship and disparaging the specific computerized measurement devices and the dentists using them in the management of their TMD patients using neuromuscular occlusion dental treatment.     

光生物调节治疗颞下颌关节紊乱病患者疼痛效果的Meta分析

目的    评价光生物调节治疗颞下颌关节紊乱病患者疼痛效果,为临床提供参考依据。方法    计算机检索PubMed、Embase、Cochrane Library、中国知网、万方、维普等数据库,查找光生物调节治疗颞下颌关节紊乱病相关文献。应用Meta分析评价光生物调节（研究组）与放置激光光纤但不予激光照射（对照组）治疗颞下颌关节紊乱病患者疼痛效果,将视觉模拟评分（visual analogue scale,VAS）、压力疼痛感受阈值（pressure pain threshold,PPT）、最大自由开口度（maximum mouth opening,MMO）、左右侧侧方运动（left lateral excursion,LLE;right lateral excursion,RLE）及前伸运动范围（protrusion excursion,PE）作为评价指标。结果    纳入了7篇相关文献,共8项随机对照研究。Meta分析结果发现,与对照组相比,研究组能明显改善VAS和PPT（均P < 0.05）。但两组在改善患者MMO、LLE、RLE、PE方面,差异无统计学意义（均P > 0.05）。分析其中6项针对慢性颞下颌关节紊乱病疼痛效果的随机对照研究结果显示,光生物调节能显著改善VAS（P < 0.05）。结论    光生物调节治疗能较好地改善颞下颌关节紊乱病患者的疼痛症状,对慢性疼痛患者的疗效也较好,但对于下颌运动障碍的改善不明显。     

Outcome of eminectomy combined with discectomy and silastic interpositional graft for temporomandibular joint dysfunction: a retrospective study of 20 years

Internal derangement of the temporomandibular joint (TMJ) is usually treated conservatively, but about 5% require surgical treatment. We designed a retrospective study to assess the long-term outcomes of eminectomy combined with discectomy and silastic interpositional graft in 44 patients who had chronic TMJ dysfunction that had not responded to traditional conservative treatment and arthrocentesis. The maximum mouth opening, pain score, Wilkes stage, and clinical dysfunction index were measured before, and two years after, operation. All the patients showed significant improvement in mouth opening and reduced pain scores (p < 0.0001 in each case). There were no long-term operative complications, and postoperative magnetic resonance scans showed that the silastic interpositional graft was in a stable position with no evidence of degenerative changes on the surfaces of the joint and no lymphadenopathy.     

Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders

This study was performed to assess the prevalance of signs and symptoms of temporomandibular disorders (TMD) in patients with cervical spine disorders (CSD) and to compare patients with CSD and subgroups of patients with TMD with regard to the results of orthopaedic tests of the stomatognathic system. A group of 103 consecutive patients with signs and symptoms of CSD and a group of 111 consecutive patients with TMD were examined. All subgroups of TMD patients showed a significantly smaller range of motion than the CSD patients. Patients with TMD had limited mouth opening (<40 mm) on active and passive mouth opening more often than CSD patients. TMD patients with myogenous problems reported oral habits more often than CSD patients, although no objective differences between CSD and TMD patients were found. Subgroups of TMD patients reported joint sounds, and pain on palpation and joint play tests of the temporomandibular joint (TMJ) more frequently than CSD patients. Joint sounds on active movements, pain on palpation of the TMJ, and pain on joint play tests correctly classified 82% of the patients with TMD and 72% of the patients with CSD. In spite of the biomechanical and anatomical relationship between the neck and the stomatognathic system, the results of the study show that CSD patients have signs and symptoms of TMD comparable with those of the adult Dutch population. It was concluded that the function of the masticatory system should be evaluated in patients with neck complaints in order to rule out a possible involvement of the masticatory system.     

Oral parafunctions and association with symptoms of temporomandibular disorders in Japanese university students

We examined whether oral parafunctions are associated with symptoms of temporomandibular disorders (TMD) in 3557 Japanese university students, aged between 18 and 26 years. Participants completed a questionnaire regarding various oral parafunctions and subjective symptoms related to TMD, and underwent a dental examination. The prevalence of temporomandibular joint (TMJ) noise, TMJ pain and impaired mouth opening was 41.7, 16.0 and 16.3%, respectively. The most prevalent parafunction was sleeping on one side (60.2%), followed by supporting the jaw by leaning on the palm of the hand (44.8%). Mean age, decayed, missing and filled teeth, and number of teeth were not significantly different between TMD positive and negative groups according to unpaired t-test. The chi-squared test revealed that the ratio of females was significantly higher among students with TMD than without TMD. Multiple logistic regression models adjusted for age and gender demonstrated that chewing on one side caused an increased risk of TMJ noise [odds ratio (OR) = 1.52, P < 0.001], TMJ pain (OR = 1.54, P < 0.001), and impaired mouth opening (OR = 2.00, P < 0.001). Tooth clenching also increased the risk of TMJ noise (OR = 1.86, P < 0.001), TMJ pain (OR = 1.79, P = 0.001) and impaired mouth opening (OR = 1.88, P < 0.001). Further prospective cohort studies, including other potential risk factors, are required to clarify these relationships.     

Role of panoramic radiographis in differential diagnosis of patients with temporomandibular dysfunction

We reviewed the records for 4 patients with temporomandibular disorders (TMD), in all of whom temporomandibular joint (TMJ) arthrosis was initially suspected because of the clinical symptoms such as limited mouth opening and pain at the TMJ region. However, careful observation of the panoramic radiographs disclosed abnormalities other than TMJ arthrosis, including, obliteration of the posterior maxillary sinus wall (caused by squamous cell carcinoma of the maxillary sinus), resorption around the condylar neck (caused by hemangioma), and radiopaque foci at the anterior area of the right TMJ (synovial chondromatosis). Some of these abnormalities were not observed on the oblique lateral transcranial projection and the transorbital projection. Although panoramic imaging provides rather blurred images of the TMJ region it produces a broad image of the maxillofacial region which is helpful in the detection of neoplasms and other disorders. Its careful interpretation should be emphasized especially in the differential diagnosis of TMD.     

Widespread mechanical pain hypersensitivity in patients with chronic migraine and temporomandibular disorders: relationship and correlation between psychological and sensorimotor variables

Objective: This study aimed to assess mechanical hyperalgesia in the trigeminal and extra-trigeminal regions in patients with chronic migraine (CM) and temporomandibular disorders (TMD) in comparison to asymptomatic subjects and to determine the association between sensorimotor variables and psychological and disability variables and evaluate the prediction of a sensorimotor variables though psychological and disability variables in patients with CM and TMD.

Material and methods: A total of 52 subjects with concomitant CM and TMD and 30 asymptomatic subjects were included in the study. The pressure pain threshold (PPT), maximal mouth opening (MMO) and a series of self-reported factors were compared.

Results: There were 52?CM and TMD (92.3% women and 7.7% men; age?=?46.2?±?9.5) and 30 asymptomatic subjects (80% women and 20% men; age?=?47.4?±?10). Differences were found between patients with CM and TMD and asymptomatic participants (p?<?.01) when comparing the PPTs in the trigeminal and extra-trigeminal regions. The PPT for the trigeminal region was predicted by depressive symptoms (variance of 18%) as well as disability and craniofacial pain (variance of 20%). The extra-trigeminal region PPT was predicted by depressive symptoms (variance of 10%), and pain-free MMO was predicted by disability and craniofacial pain (variance of 24%).

Conclusions: This study suggests that patients with CM and TMD present with generalized mechanical hyperalgesia. In addition, an association between sensorimotor, psychological and disability variables was observed.     

Correlation between oral parafunction and temporomandibular disorders and emotional status among saudi children.

Studies on association between temporomandibular disorders and oral parafunction in preschool children are few. The aim of the present study is to investigate the relationship between the subjective and objective signs and symptoms of temporomandibular disorders (TMD), oral parafunction and emotional status in preschool children. The study is based on a clinical examination and questionnaire. Five hundred and two Saudi children aged 3 to 7 years were examined for different signs and symptoms of TMD. In addition, the parents of the children were given a questionnaire to investigate the existence of oral parafunction and evaluate the emotional status of children. The results of the study showed significant association between attrition and temporomandibular joint (TMJ) pain, muscle tenderness and restricted opening, (P Values were 0.008, 0.019, 0.037 respectively). Significant association was found between habit of grinding and pain, while eating or opening the mouth (P<0.012). Significant association was found between emotional status and multiple signs and symptoms of TMJ tenderness, TMJ pain and muscle tenderness (P<0.042). Significant association was found between emotional status and pain, while eating or opening of the mouth (P<0.048). Close to positive association was found between oral parafunction and jaw lock. The association between TMD and oral parafunction as well as emotional status should direct the attention of the dentist to the importance of considering the emotional status, oral parafunction and TMD when examining and formulating treatment plan for the child patient.     

JOINT DISORDER: NONREDUCING DISC DISPLACEMENT WITH MOUTH OPENING LIMITATION – REPORT OF A CASE

The internal derangement of the temporomandibular joint (TMJ) represents 8% of all cases of temporomandibular disorders (TMD) posing difficulties to establish an accurate diagnosis and treatment because of its low prevalence. This article presents the case of an 18-year-old Caucasian female patient who came to our Orofacial Pain and TMD Outpatient Service with complaints of intense pain on the right TMJ and limitation of mouth opening (maximum interincisal opening of 29 mm) with deviation to right, which she had been experiencing for the past 3 years. After a detailed clinical interview, a diagnosis hypothesis of nonreducing disc displacement with mouth opening limitation was established. The proposed treatment consisted of intra-joint infiltration with anesthetic in the right TMJ followed by jaw manipulation to recapture the articular disc, which was impeding the complete translation movement of the affected TMJ. After jaw manipulation, a new evaluation was done and showed the re-establishment of jaw dynamics with mouth opening and closing without deviation to the right side, clicking, opening limitation or pain. The patient was followed up at 6 months intervals. Two years after treatment, the patient was reevaluated and her mandibular range of motion without aid increased to 54 mm with no clicking, deviation to right, trismus or pain on the TMJ, indicating success of the treatment approach without recurrence of the pathology.     

Terapia conservativa in pazienti con disordini temporomandibolari: risultati preliminari

Objectives

To evaluate the effect of conservative therapy for the treatment of patients with temporomandibular disorders (TMD).

Materials and methods

In this clinical, retrospective, before-and-after study, we reviewed clinical chart data and selected 28 outpatients with TMD. Inclusion criteria were TMD that was mainly functional and biomechanical in origin, treatment with conservative measures, availability of 3-month follow-up data. Conservative treatment consisted of one or more of the following: occlusal appliances, active physical therapy exercises, manual therapy, and stress management techniques. The following outcome measures were evaluated: craniofacial pain and mouth opening at base-line and after treatment at the 3-month follow-up.

Results

As a result of treatment, follow-up assessments revealed significant improvements in pain and mouth opening (t test for paired samples, p < 0.01).

Conclusions

Despite the limitations of this study, our findings indicate that conservative therapy may be useful in the treatment of patients with TMD. This conclusion is in line with international guidelines, which recommend noninvasive, reversible interventions for the initial treatment of TMD.     

The comparison of outcomes of surgically treated bilateral temporomandibular joint disorder in different groups: A retrospective study

Objectives: The main purpose of this study was to determine the prognosis and outcomes of the patients with bilateral temporomandibular disorder which underwent bilateral temporomandibular joint surgery in a consecutive number of patients in a retrospective study. Study Design: Sixty five patients with 130 bilateral TMJ were included the study with the selection from consecutive 256 TMJ patients who were treated with open surgery who do not respond to conservative treatment. 65 patients were divided in to 3 main groups according to the clinical diagnosis of bilateral TMJ site. In the first group comprised 29 patients with 48 TMJ, the clinical diagnosis was bilaterally presence of anterior disc displacement with reduction (ADDR). In the second group comprised 19 patients with 26 TMJ, bilateral presence of TMD consisted of anterior disc displacement without reduction (ADDNR) on both site. In the third group comprised 27 patients with 46 TMJ, bilaterally presence of TMD consist of ADDR on one site and ADDNR on another site. The patients in three different groups were operated either high condylectomy alone or high condylectomy with additional surgical procedures. Results: In the evaluation of pain relief, clicking, crepitation, headache, marked improvement was determined in all groups, but it was statistically insignificant in the comparison of 3 groups. Slight increase in maximal mouth opening was determined in the mean values of the 3 groups and also in the comparison of 3 groups it was not statistically significant. Conclusions: These similar succesfull outcomes of bilateral TMD with the respect of TMJ surgical procedures were obtained in 3 main groups although different diagnosis on the patients’ groups waspresent. Key words:Temporomandibular joint, prognosis, retrospective studies.     

单纯透明质酸注射治疗对颞下颌关节功能和结构的影响

目的：利用MRI评价颞下颌关节功能和结构在透明质酸治疗前后的变化。方法：选取经过颞下颌关节门诊治疗的TMJ结构紊乱患者23例行单纯关节上腔透明质酸钠注射治疗。23例患者中,男性3例,女性20例,年龄16~58岁,平均年龄27.8岁。利用MMO及VAS评价患者颞下颌关节功能治疗前后的变化;并对所有患者进行治疗后颞下颌关节MRI检查,评价颞下颌关节结构变化。结果：23例经HA治疗的患者,治疗前MMO 25.90、VAS5.78。治疗后MMO 35.12、VAS1.42,经统计学处理,有统计学意义（P〈0.05）。MRI检查显示治疗后23例患者中均未发现颞下颌关节盘复位。结论：单纯经关节上腔注射HA治疗颞下颌关节结构紊乱可有效改善患者功能,但对颞下颌关节结构无明显影响。     

Is there a difference in treatment effect of different intra-articular drugs for temporomandibular joint osteoarthritis? A systematic review of randomized controlled trials

A systematic review based on the PRISMA guidelines was conducted to investigate and compare treatment with hyaluronic acid (HA), corticosteroids, and blood products in patients with temporomandibular joint osteoarthritis (TMJOA). The MEDLINE/PubMed, Embase, and Cochrane Library databases were searched for articles published until September 25, 2019. Articles met the inclusion criteria if they reported patients with TMJOA, a comparison group, and a follow-up period of at least 6 months. The mean and standard deviation for TMJ pain and maximum mouth opening (MMO) were reported. Nine studies involving 443 patients were included. Injectables and Ringer’s lactate solution or normal saline were reported to significantly improve TMJ pain and MMO. Regarding TMJ pain, two studies showed a significant superiority of plasma rich in growth factors (PRGF)/platelet-rich plasma (PRP) injections with or without arthrocentesis over HA, but HA showed a significant improvement compared to corticosteroids. For MMO, no injectable was found to be superior to Ringer’s lactate or a normal saline control, but arthrocentesis + PRP resulted in MMO improvement compared to arthrocentesis + HA. Overall, all injectables in conjunction with arthrocentesis were efficient in alleviating pain and improving MMO in TMJOA patients; however, a meta-analysis was not possible due to heterogeneity across studies.     

Comparison of two physiotherapy programmes for rehabilitation after temporomandibular joint arthroscopy

The purpose of this study was to compare two physiotherapy programmes for rehabilitation after temporomandibular joint (TMJ) arthroscopy. The medical files of 137 consecutive patients diagnosed with closed lock and treated by arthroscopic lysis and lavage were analyzed retrospectively. Sixty-eight patients were rehabilitated with gradually increasing range of motion self-exercises (gradual programme) and 69 patients were rehabilitated with immediate full range of motion self-exercises (immediate programme). The outcome variables were maximum mouth opening (MMO) and pain (on a visual analogue scale). The postoperative measurements taken at 1 month, 6 months, and last follow-up examination available (mean of 10 months postoperative) were analyzed and compared between the two groups. The results showed significantly better MMO and pain outcomes for the immediate group than for the gradual group at the 1-month and 6-month postoperative evaluations. The results of the two groups were comparable at the last follow-up examination available. It is concluded that after arthroscopic treatment of closed lock of the TMJ, a physiotherapy programme consisting of immediate postoperative full range of motion mobilizations achieves better results (in terms of pain and mouth opening) than a physiotherapy programme consisting of gradual and controlled increases in range of motion.     

Anamnestic index severity and signs and symptoms of TMD

The aim of this study was to determine the frequency and to characterize the symptoms and clinical signs of temporomandibular disorders (TMD) related to each severity category of Fonseca's anamnestic index in a sample of Brazilian young adults (mean age 21.61+/-1.91 years, 87% females and 13% males), by the application of an anamnestic index proposed by Fonseca (1992) and by clinical examination considering mandibular range of motion and tenderness to palpation of stomatognathic system structures. A significant number of participants were classified with mild TMD (43.2%) and moderate TMD (34.8%). Pain frequency during mastication, temporomandibular joint (TMJ) pain, and TMJ sounds were shown to be good predictors of TMD severity. Neck pain, headache, difficulty during mouth opening and lateral deviation, and tenderness to palpation of masticatory sites and during protrusion accompanied the TMD severity but failed to demonstrate differences between moderate and severe groups, showing a poor ability to determine TMD severity progression. This study suggests that not only the frequency of signs and symptoms of TMD should be determined, but also symptom severity and its relationship to the presence of clinical signs in order to discriminate patients with real treatment needs in nonpatient samples.     

Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI

Forty-eight (48) consecutive patients seeking treatment in a referral based practice for complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess specific symptom relief from anterior repositioning appliance (ARA) therapy and the relationship between specific symptom relief and the status of the TMJ disk. Each patient was assessed on 86 symptoms based upon whether each symptom was present before treatment and absent, better, unchanged or worse after Maximum Medical Improvement (MMI). The most common symptom was occipital cephalalgia (94%). The least common symptom was pain and burning of tongue (8%). A profile of a temporomandibular disorder (TMD) patient was developed. The typical TMD patient has cephalalgia, mainly in the occipital, temporal and frontal region, pain upon chewing food, pain upon opening and closing the mouth, TMJ pain, pain in the back of the neck and difficulty chewing food. Before treatment, patients with bilateral displaced disks had more symptoms than those with unilateral displaced disks and the opposite side normal. After MMI, the maximum benefit (percent of pretreatment symptoms relieved) was found in patients with normal or recaptured disks. The minimum occurred in patients whose disks did not recapture with therapy. ARA therapy improved or eliminated symptoms in all patients in the study.