INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016 Available online at www.ordoneardentistrylibrary.org ISSN 2249-488X Review – report...
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Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016 Available online at www.ordoneardentistrylibrary.org

ISSN 2249-488X

Review – report

INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY COMPREHENSIVE REVIEW OF TEMPOROMANDIBULAR JOINT DISORDER MANAGEMENT Dr Shefali Singla*, Dr Lalit Bida, Dr Sharique Rehan Dr. Harvansh Singh Judge Institute of Dental, Sciences and Hospital, Panjab University, Chandigarh,India Received: 17 Dec. 2015; Revised: 29 Jan. 2016; Accepted: 15 Feb. 2016; Available online: 5 Mar. 2016

ABSTRACT There is continuing debate regarding epidemiology, etiology, diagnosis and management of temporomandibular disorders(TMD).The multifactorial nature of TMD and oral facial pain and the number of conditions with similar signs and symptoms demands an effective differential diagnostic procedure. Little is known about the natural course of the various categories of TMD and most treatment approaches have been reported to be effective in various reviews and case reports, but there is lack of scientific foundation. A conservative, noninvasive management programme is endorsed with emphasis on a multidisciplinary approach. This review aims to help clinicians better understand TMJ disorders ,diagnosis and recognition of signs and symptoms and treatment concepts to reach a rational conclusion regarding treatment plan. Key words:Temporomandibular joint dysfunction, Bruxism, Occlusal splint, Occlusal therapy

INTRODUCTION Temporomandibular joint disorder (TMD) is a broad term including all problems pertaining to TMJ and related musculoskeletal structures with myofacial pain as its most common manifestation. Inspite of multitudinous research activities, the etiology of TMD is still an enigma. So the management of TMD patients is a particular challenge for the dentist and is characterized by considerable heterogeneity. Diagnosis of all predisposing,initiating and perpetuating factors is the key to successful treatment.This review aims to help clinicians better understand TMJ disorders ,diagnosis and recognition of signs and symptoms and treatment concepts to reach a rational conclusion regarding treatment plan. Etiology There are two distinct categories of TMD –Masticatory muscle disorders and Joint disorders (Table 1) and these are interrelated to eachother. Joint disorder is caused by altered condyle-disc-fossa relations and disc derangements that are associated with loss of vertical dimension, posterior tooth support loss and or other malocclusions. Stress is an indirect contributing factor that usually works through the medium of clenching according to Weinberg.[1] Occlusal disharmonies increase noxius input to neuromuscular system and also stressinduced clenching, causing increased muscle activity and spasm. Genetic and metabolic factors may contribute by lowering the threshold of tissue damage from overloads or trauma. First signs of TMDs are pain, soreness of jaws and muscles, clicking or popping sounds during opening movements because of disc interference ,muscle spasm and limitation or deviation in mandibular range of. 1

Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Common patient complains include headache,neckache,face ache, and ear ache.TMD, though not life threatening is certainly life altering. Management Treatment efforts are generally directed towards reduction of pain, relaxing muscles of mastication, stabilize craniomandibular relationship and reduce adverse loading of TMJ. TMD management is a multidisciplinary effort in phased manner. Phase I therapy is a conservative, noninvasive and reversible regime that includes diet and behavioral modification[2],pharmacotherapy[3],physical therapy and interocclusal devices[4]. Success of PhaseI therapy in relieving pain and discomfort can eliminate/minimize the requirement of Phase II therapy that includes surgical correction of pathology and occlusal therapy.[5,6] All Phase I therapies must be exhausted before undertaking the invasive/irreversible procedure.Conservative phase I treatments decrease signs and symptoms in 86% of patients with TMJ disorders.[7] Diet and Behavioral modifications- Patient is put on soft diet to reduce occlusal loads and patient’s stress and habits are managed by counseling and psychotherapy. Patient is advised to avoid chewing hard food, gum, yawning, singing, excessive talking, clenching and abnormal sleep routine. Pharmacotherapy- No single drug has total effectiveness in TMD but over the years use of various analgesics and anti-inflammatory drugs have shown patient improvement. Analgesics and corticosteroids are advocated in acute TMD pain, nonsteroidal antiinlammatory drugs (NSAIDS) and muscle relaxants in both acute and chronic disorders and tricylic anti-depressants in chronic situations.[8] Benzodiazepines are sedative-hypnotic drugs with antianxiety effect and are used short-term(2.5-5mg before sleep not more than 10 days) only for acute muscle pain and sleep disturbances associated with anxiety. Physical therapy- This includes hot and cold moist packs, ultrasound, Galvanic Stimulation, Transcutaneous electrical nerve stimulation(TENS), Iontophoresis, acupuncture and low level Laser.[9] Increase in temperature of tissues leads to increased blood flow at the site and relief from pain. Range of motion exerciseen are advised like opening the mouth to a comfortable fully open position and then applying slight additional pressur e to open the mouth fully. Another is making various facial expressions to stretch the jaw muscles.[10] Botox injections – Their use was first reported 20 years ago in eliminating muscle spasm and decreasing contraction intensity while retaining voluntary control.[11] Since then it has been reported as effective method for treating severe bruxism when traditional methods fail.[12,13] Interocclusal devices/Splint Therapy – Many splint designs have been described (Table 2) over the years for diagnosis and treatment of various TMD’s. According to GPT 8, an occlusal splint is any removable artificial occlusal surface used for diagnosis or therapy affecting the relationship of mandible to the maxilla. It may be used for occlusal stabilization, for treatment of TMJ disorders, or to prevent wear of dentition.The primary purpose of splints is to reduce pain and muscle activity by slightly increasing vertical dimension and/or achieving posterior disocclusion.[14] Splint therapy reversibly alters the occlusion in accordance with centric 2

Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

relation(CR) position except in joint inflammation case where an anteroinferior position is used untill information subsides (approximately 7 days) . Rapid reduction in pain and discomfort with the use of a splint may be an indication of muscular problem, but if symptoms worsen with splint wear,it may indicate an internal disk derangement. These appliances provide palliative treatment and should not be used beyond three months in noninjury patients.[1] In trauma cases anterior repositioning splints are advocated for short-term use(upto initial 10 days) when stabilization splints tend to increase pain by allowing condyle free access to inflamed tissues in retrodiscal area.[15] Prolonged wear of repositioning splints tends to introduce posterior open bite which would need extensive orthodontic and restorative procedures to occlude the teeth in this anteroinferior position of condyle. Splints don’t actually heal the patient but create a situation where tissues can heal themselves in absence of pathology and prolonged injudicious use of splints can cause more harm than benefit. Surgical therapy- If pain cannot be resolved with phase I therapy, accepted criteria can be applied to determine whether open or closed surgery is indicated. Accepted effective surgical procedures have been listed as disc repositioning surgery,arthrocentesis,arthroscopy,condylotomy,arthrotomy,coronoidectomy,styloidectomy and joint replacement procedures. Post-operative care should include wound care,hot packs, soft diet and active/passive joint exercise to increase range of motion.[16]. Occlusal therapy-In patients where phase I therapy has been able to control pain and distress, phase II occlusal therapy can be given to restore disturbed occlusion if indicated. This includes occlusal equilibration, restorative dentistry, orthodontics, or orthognathic surgery.The thumb rule is to proceed carefully, using the least invasive procedure.Functional equilibrium established by TMD management programme should be maintained, especially when intercuspal position(ICP) and the vertical dimension of occlusion are acceptable. If a functional equilibrium has not been achieved or if ICP and VD need to be altered, occlusal scheme has to be reestablished, a treatment reference position has to be established, essentially centric relation, to allow clinician to design treatment from a known starting point. Ongoing TMD therapy, such as physical therapy,pharmacotherapy, or behavioral therapy should be continued during the prosthodontic treatment. Fixed restoration should be temporarily cemented and monitored regularly.A segmental approach should be followed for final cementation.[17] Conclusion The management of TMD patients is

particularly challenging for the dentist because of interrelated

multifactorial etiology. There is a close relation of intracapsular joint disorders to masticatory muscle disorders. Ideally TMD should be treated by designated members of an established multidisciplinary team. Injudicious use of even conservative phase I therapy,like occlusal splints can cause irreversible damage. After the dysfunction has been treated, only then restorative/occlusal therapy is given to establish a healthy functional occlusion. There is limited scientific data supporting TMD management and lack of solid understanding of

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Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

TMD is reflected in considerable variations in treatment approach. More scientific research is needed to create a better understanding of TMD puzzle. References 1.Weinberg LA.Definitive of different prosthodontic therapy for TMJ patients.Part I:Anterior and posterior condylar displacement.JProsthet Dent.1983;50:544-57. 2.Pierce CJ, Gale EN. A comparison treatments for nocturnal bruxism.J Dent Res.1988;67:351-75. 3.Gregg JM, Rugh JD.Pharmacological therapy.In.Mohl ND,Zarb GA, Carlsson GE,Rugh JD,eds. Atextbook of occlusion. Chicago;quintessence 1988;67:597-601. 4.Kirk WS,Calabrese DK.Clinical evaluation of physical therapy in the management of internal derangement of Temporomandibular joint.J Oral Surg.1989;47;113-9. 5. Clark GT, Adler RC. Acritical evaluation of occlusal therapy:occlusal adjustment procedures.J Am Dent Assoc.1985;110:743-50 6. Clark GT, Mohl ND, Riggs RR.Occlusal adjustment therapy.In: Mohl ND, Zarb GA, Carlsson GE, Rugh JD,eds.A textbook of occlusion. Chicago, Quintessence 1988:285-303. 7.Mortazavi, S. H. Motamedi MHK, Navi F, Pourshahab M, Bayanzadeh SM, Hajmira‐gha H, Isapour M: Outcomes of management of early temporomandibular joint dis‐orders: How effective is nonsurgical therapy in the long-term? National J MaxillofacSurg.2010;1(2):108-11. 8.Jaffe JH,Martin JR.Analgesics and antagonists,In:Goodman A,Gilman L,editors.The pharmacological basis of therapeutics.7th ed.New York:Macmillan,1985:491-532. 9. Lassemi, E, & Jafari, S. M. ,Motamedi MHK, Navi F, Lasemi R: Low-level Laser Therapy in the Management of Temporomandibular Joint Disorder. J of Oral Laser Applications.2008;8:83-86. 10.Au AR, Klineberg IJ.Isokinetic exercise management of temporomandibular joint clicking. Jprosthet Dent.1993;70;33-9. 11.Scott AB.Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery.Ophthalmology.1980;87:1044. 12.Freund B, Schwartz M, Symington JM. The use of Botulinum toxin for treatment of temporomandibular disorders:preliminary findings.J Oral Maxillofac Surg.1999;57:916. 13.TanE-K,JankovicJ:Treating severe bruxism with Botulinum toxin.J Am Dent Assoc.2000;131:211. 14.Weinberg LA.The use of treatment prosthesis in TMJ dysfunction pain syndrome.J Prosthet Dent.1978;39:1978. 15.Dylina TJ. A common sense approach to splint therapy. J Prosthet Dent.2001;86:539-45. 16.McCarty WL,Darnell MW.Rehabilitation of the temporomandibular joint through the application of motion.J Craniomandibular Pract .1993;11:298.

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Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

17.Turp JC and StrubJR. Prosthetic rehabilitation in patients with temporomandibular disorders.J Prosthet Dent.1996;76:418-23.

Table 1: Etiology and diagnostic assessment of Temporomandibular Disease Category TMD

of Etiology

1.Masticatory muscle disorders/ Extracapsular

2.TMJ Disorders/ Intracapsular

-Stress induced bruxism and clenching -Referred pain of cervical spine -Systemic muscular disorders like Myositis,FibromyalgiaDysplasia s, Infection,Arthritides, hypertrophy and atrophy.

Signs and symptoms

-Unilateral/Bilateral dull pre-auricular pain. -May exhibit hypertrophy and fatigue of masticatory muscles -Worsening of pain in morning due to clenching/grinding -Tenderness over affected muscles as well as limited jaw function -Intermittent decrease in mandibular movement -poorly localized pain

-Physiologic joint deformation - Unilateral/Bilateral pain due to destructive forces/trauma with or without popping -Diskdisplacement or crepitus reducing/nonreducing* -Pain is continuous, -Disk adhesions,perforations or localized to joint and fibrosis increase with function -Joint dislocation -Mandibular hypo-or -Inflammatory conditions like hypermobility Synovitis and Capsulitis -Osteoarthrosis and osteoarthritides -Fibrous or bony ankylosis *depending on return of disc to correct position during translational position.

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Diagnostic tests and Examination -Standard TMJ X rays,Computeriz ed tomography(CT) , Magnetic resonance imaging(MRI) -Differential diagnostic blocks with Local anaesthetic -Therapeutic trial of medication like NSAID’s or muscle relaxants -Tomographic TMJ radiographs,CT, MRI -Appropriate lab tests e.g.rheumatoid panel

Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Table 2: Types of Interocclusal devices Name of Splint Design Types Function Permissive splints/Muscle deprogrammers-Flat plane appliances that are designed to unlock occlusion,which in turn allows condyle-disc assembly to function anatomically. 1.Anterior Preferably mandibular -Anterior Jig/Lucia Jig -Eliminates proprioceptive midpoint contact hard splint allowing -Anterior Bite Plane feedback from -Nociceptive splints contact of one or more anterior teeth effecting Trigeminal inhibition posterior teeth and interrupts mandibular posterior disocclusion, (NTI)Splint position sense thus eliminating their -B Splint muscle influence on the -Hawley with bite -Reduces activity. plane mastcatory system. -Sved plate -Alters vertical -Stabilization 2.Full Contact Maxillary/mandibular splint full coverage hard splint splint/Centric relation dimension -Provides mandibular constructed to centric splint position relation position. -Michigan splint deprogramming Provides even posterior -Shore eliminating contacts at closure, appliance(maxillary discrepancy between splint without facial anterior disocclusion and CR and maximal canine guidance or group coverage) function in lateral -Tanner (mandibular) intercuspal position(MICP) excursions with no splint -Relieves muscle and balancing side contacts. joint pain especially from occlusal contact discrepancy or parafunctional habits. Directive splints- Designed to position the mandible in a special desired relationship to maxilla with an aim to align condyle-disc assembly in a more favorable position so that normal function can be established 1.Anterior Typically maxillary hard -Anterior repositioning -Allows retrodiskal repositioning splint that places splint tissues to heal device mandible in a position -Ligated anterior sufficiently to regain a forward to MICP so as to repositioning backward pull on disk prevent full seating of splint(LARS) in disc interference condyles and disorders mechanically recapturing -Indicated in patients disk back on top of with joint sounds such condylar head as single or reciprocal clicks,chronic locking of joint and inflammatory disorders(retrodiscitis) 2.Posterior bite Hard,mandibular -Mandibular -To restore vertical plane posterior coverage splint orthopedic dimension in case of with a lingual bar repositioning appliance severe loss connecting posterior (MORA) -Mandibular 6

Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Dr Shefali Singla et al . / IJRID Volume 6 Issue 1 Jan.-Feb 2016

Other types Pivot splint

Soft/Resilient splint

Hydrostatic Splint

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segments.Changes -Gelb Splint posterior occlusal contacts and eliminates anterior tooth contacts.Prolonged use might cause supraeruption of unopposed anterior teeth and posterior open bite.

repositioning

Hard mandibular splint Distraction splint with occlusal contact only on most posterior tooth in both quadrants.Clenching on the pivot pulls condyle downward relieving traumatic load on articular surfaces and freeing disk to reassume a normal position. Full coverage appliance -Mouth guard made of resilient material -Night guard to achieve even ,simultaneous contact with opposing teeth.

-To treat interarticular pressure and unload the joint -To treat degenerative joint disease -Treat joint sounds

Fluid filled reservoir Aqualizer covering the teeth to balance the biting pressure and to treat TMJ pain. All occlusal disharmonies arecompensated by distribution of fluid within the reservoir. Forces become systematically equalized and axially oriented.

-Emergency appliance for acute TMJ condition -For treatment of Bruxism and clenching -Protective device for athletes and sportsperson -To equalize occlusal forces and relieve pain in TMJ disorder.

Dr Shefali Singla et al / IJRID Volume 6 Issue 1 Jan.-Feb 2016

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