Tuesday, April 8, 2014

The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders

The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders

Cooper, B.: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology Volume 83, Issue 1 , Pages 91-100, January 1997.


Temporomandibular disorders (TMDs) can affect the form and function of the temporomandibular joint, masticatory muscles, and dental apparatus. Electronic measurement of mandibular movement and masticatory muscle function provides objective data that are defined by commonly accepted parameters in patients with TMDs; these data can then be used to design and monitor therapy and enhance treatment therapy. In this study, data on 3681 patients with TMD are presented, including electronic test data on 1182 treated patients with TMDs. Electronic jaw tracking was used to record mandibular movement and to compare the presenting and therapeutic dental occlusal positions. Electromyography was used to analyze the resting status of masticatory muscles and occlusal function at presentation and after therapeutic intervention. Transcutaneous electrical nerve stimulation therapy relaxed masticatory muscles and aided in the determination of a therapeutic occlusal position. The data show a positive correlation between the clinical symptoms of TMD and the presenting occlusion, accompanied by muscle activity. A strong positive correlation also appears to exist between a therapeutic change in the dental occlusion to a neuromuscularly healthy position with use of a precision orthotic appliance and the significant relief of symptoms within 1 month and at 3 months.

Monday, April 7, 2014

Precision occlusal splints and the diagnosis of occlusal problems in myogenous orofacial pain patients

Precision occlusal splints and the diagnosis of occlusal problems in myogenous orofacial pain patients 
Glenn M. Kidder, DDS, FAGD and Roger A. Solow, DDS, General Dentistry, 2014 Mar/Apr; 62(2):24.

Myogenous orofacial pain is a common nondental pain. There is an unresolved debate on the etiology of this problem. Research has shown that occlusal interferences affect masticatory muscle comfort, coordination, and function. Resolution of these problems with precise occlusal correction indicates that dental occlusion is a causative or contributory factor in myogenous orofacial pain. However, some studies fail to confirm this and instead conclude that occlusion is unrelated to masticatory muscle pain or dysfunction. An explanation for this discrepancy in findings is that these nonconfirmatory studies had not documented any pretreatment or corrected occlusion. Diagnostic casts mounted in centric relation and precision occlusal splints are accurate modalities to diagnose the occlusal problem and its correction in a patient with myogenous orofacial pain. Computerized digital occlusal analysis provides objective data of occlusal contact time and force to accurately assess diagnosis and treatment. The rationale and requirements for proper occlusal splint fabrication with a verified therapeutic occlusion re presented.

"Patients cannot avoid the effect of traumatic occlusal contacts without dental treatment. Many myogenous orofacial pains do not follow a natural course of remission. A treatment approach based on accommodation to symptoms is not optimal if a structural cause is not identified and treated. Ignoring progressive nonpainful damage to teeth such as wear, fracture, and abfraction is not ethical when OS [occlusal splint] or OA [occlusal analysis] can limit that damage. Dentists are the only health care professionals trained to diagnose and treat myogenous orofacial pain that is related to occlusion. A default decision that pain or dysfunction is a psychological problem without ruling out a physiological cause is presuming a diagnosis."

Studies by Kerstein et al established the importance of objective occlusal analysis in TMD diagnosis and treatment.7,64-73 They proved a scientific rationale for anoptimal occlusion to prevent adverse force
on restorations and treat myogenous orofacial pain. These studies span 22 years; to date there is no literature that refutes the physiological model for masticatory muscle pain, the validity of the T-Scan
technology, or the documented clinical results. Computerized occlusal analysis objectively quantifies forces without relying on subjective and inaccurate patient input. Dentists can use this technology
to document and deliver an optimal OS occlusion.

Occlusal correction may play a significant role in the treatment of myogenous orofacial pain when a structural problem is confirmed with objective occlusal analysis. There is extensive literature showing
adverse occlusal forces are not beneficial to the patient and should be corrected as part of optimal care. It is the dentist’s responsibility to assess the structural component of each patient’s problem set.
Precision OS therapy can assist this evaluation and preview the effect of definitive occlusal correction.

Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients

Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients
Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc. J. Cranio. Practice, April 2008, Vol. 26, No.2, pp. 104-117.

The objective of this investigation was to test the hypothesis that alteration of the occlusions
of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly,
rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

One theory proposed as the basis of TMD is that it is mainly the result of a dysfunctional masticatory system that is characterized by complicated interactions between various muscles, two temporomandibular joints, and a moveable mandible that supports a cadre of teeth that engage in complex and intermittent interdigitations. It then follows that a desired goal of treatment is to identify
and improve or correct any dysfunctions and correct the cause or causes of TMD and any related pain.

The objective of this study was to determine: (1) whether patients who presented with chronic symptoms of TMD could be objectively brought from a state of neuromuscular dysfunction to a state of neuromuscular function using the instrumentation mentioned above; (2) whether orthosis treatment can facilitate changing a nonphysiological neuromuscular situation to one that is physiological; and (3) most importantly, whether such alterations result in relief and/or reduction in TMD symptoms, especially one as discomforting as pain. The current study has tested these hypotheses by retrospective
analysis of symptom data obtained in patients examined and treated for TMD in a clinical practice, where objective instrument methodology was used in conjunction with the wearing of orthotic devices to correct neuromuscular malocclusions, and thereby relieve TMD symptoms such as pain.

313 TMD pain patients were studied, 49 patients (15.9% of the test population) had occlusions that were coincident with the TENS neuromuscular trajectory. 253 (82.1%) had over-closures (excess vertical freeway space). 221 (71.8%) had posterior mandibular displacements.
166 (53.9%) had lateral displacements. Findings: Study clearly demonstrates that there is a physical dysfunctional basis for TMD, which can be corrected by establishing a neuromuscular occlusion and the use of an oral orthosis that provides this corrected occlusion. Drastic reduction in TMD symptoms were observed.
Study clearly shows that using EMG and mandibular tracking of a TMD patient’s neuromuscular occlusion, and correcting such by using orthotic devices, can result in disappearance and or substantial reduction in the number and magnitude of many of a TMD’s patient’s symptoms. This includes headaches, which in this study resulted in a 91.7% reduction in their prevalence at three months.

This approach demonstrates that drastic reduction in the magnitude of TMD symptoms can be achieved in a relatively short period of time. 
This is consistent with the ultimate goal of therapeutic intervention, to bring patients from a less healthy to a more physiologic healthy state.
Reduces in the need for medications to control pain which at best can only be temporary and incomplete solution.

Wednesday, December 16, 2009

Current Evidence Providing Clarity in Management of Temporomandibular Disorders

James Fricton, DDS, MS:Current Evidence Providing Clarity in Management of Temporomandibular Disorders: Summary of a Systematic Review of Randomized Clinical Trials for Intra-oral Appliances and Occlusal Therapies. J Evid Base Dent Pract 2006;6:48-52.

From the University of Minessota, School of Dentistry, Minneapolis, MN


The Guidelines Committee for the American Academy of Orofacial Pain conducted an evidence-based literature review to systematically search and review the literature for all randomized clinical trials for TMJD treatment using methods derived from the Cochrane Collaboration (http://www.cochrane.org/); the Oxford Centre for Evidence-based Medicine, (http://www.cebm.net/); and the Centre for Reviews and Dissemination, University of York, United Kingdom (www.york.ac.uk/ inst/crd/index.htm). Trials in which placebo, no treatment, or other treatments were used in the control group were included as were trials in which postrandomization exclusions occurred since there was no evidence that these occurred preferentially in one or other arm of the trials. This presentation reviews the results of this review for intraoral splints and occlusal therapies for temporomandibular disorders. This paper only provides a summary of the methods and results. The full results can be found in the subsequent journal publication.7

Methods of the Review
One hundred sixty-eight trials that were identified by the methods described in the search strategy were evaluated by the reviewers. Trials that proved on closer examination not to be true randomized trials were excluded. However, it is recognized that many nonrandomized studies that evaluate the efficacy of TMJD treatments including level II cohort studies, level III case-control studies and case series, and level
IV reviews of expert opinion have contributed significantly to our understanding of the treatment of TMJD. However, they were not included because of their high numbers, diversity of results, and their lower power in answering the question posed.  The knowledge gained by these studies in pilot data, study design, outcome measures, subject selection, and statistical analysis have contributed significantly in the
development of studies with more strength and conclusive results.

The results of randomized clinical trials were captured using both a qualitative and a quantitative method that could be conveyed to treating clinicians and patients. The quantitative evaluation included the NNT (number needed to treat).

For the purpose of this review, the treatments for TMJD were divided into 6 general treatment types:
1. Physical medicine treatments
2. Intraoral orthopedic appliances
3. Pharmacological therapy
4. Behavioral and psychological therapy
5. Temporomandibular joint surgery and arthrocentesis
6. Occlusal treatments

The questions to be answered for each treatment were:
1. Does the specific treatment effectively reduce TMJD pain compared to a placebo control?
2. Does the specific treatment more effectively reduce TMJD pain compared to no treatment or other treatments?

An assessment of the methodological quality of each RCT was also conducted to determine reasons for diversity of results for similar treatments and the potential for type I and type II errors. The criteria for this review and the percentage of each criterion met by the studies is presented in other papers as part of this review. The quality review was not intended to criticize the authors for the selected study designs, but rather to objectively identify source bias that may contribute to diverse or inconclusive results. The authors of these studies must be applauded for their use of an RCT, the highest level of evidence, to demonstrate efficacy of a treatment....

It was the intent of this review to conduct a meta-analysis of the data from the studies. However, in conducting the review, it was determined that the heterogeneity of studies, the varying quality, and the spareness of the similar outcomes data made it difficult to be sensibly combined....

Thirty-nine RCT studies involving intraoral splints were reviewed.9-47 In general, splints showed modest active therapeutic effects in reducing TMJD pain compared to a placebo control in more severe patients and comparable results to other treatments. In general, methodological issues in most of these studies make the results inconclusive and support the need for more well-controlled studies with improved methods. The mean quality score (0-1) of the studies was low at 0.53. Conclusions that can be drawn from this evidence-based review include the following:

1. Stabilization splints can reduce TMJD pain compared to nonoccluding splints in those subjects with more severe TMJD pain. There were no studies that demonstrated that splints work better in muscle pain, joint pain, or headache disorders, and in most studies, a mixed diagnosis of muscle and joint pain were present.
2. Stabilization splints in the short term were equally effective in reducing TMJD pain compared to physical
medicine, behavioral medicine, and acupuncture treatment for TMJD. However, the long-term effects of
behavioral therapy may be better than splints in reducing symptoms in more severe patients where psychosocial problems may be present but definitive studies have not been done. In one study, stabilization appliance therapy was more effective than pharmacological treatment for headache pain suggesting more research is needed in headache patients.
3. Anterior positioning and soft splints have some evidence to suggest that they are effective in reducing TMD pain compared to placebo controls.
4. Anterior positioning splints are at least equal to or more effective in treating TMJ clicking and locking than
stabilization splints.
5. Anterior bite planes have modest evidence of its efficacy for headaches and inconclusive evidence of effectiveness compared to a stabilization splint for TMJD pain. There is concern that partial coverage splints may contribute to tooth pain and/or occlusal changes and, thus, further study is needed before widespread use. More research is needed to study the efficacy of different types of splints for TMJD subtypes and severity and particularly, with types of headaches. Splints also need to be studied compared to placebo medications as well as other treatments including pharmacological treatment, behavioral treatment, and physical medicine procedures. The efficacy of appliance therapy for TMJDs does not only depend on appliance selection but also how well it is adjusted to facilitate patient comfort and compliance. It is
important to note that complications can occur from excessive, or incorrect use of appliances. Gingival inflammation, mouth odors, speech difficulties, and occlusal changes from these appliance can occur. Long-term, full-time use of partial coverage appliances and repositioning splints, in particular, can cause reversible changes to occlusal and functional jaw relationships. Some clinicians view orthopedic appliances as the definitive therapy for TMJD, but it is recommended that these appliances only be viewed as only part of a TMJD rehabilitation treatment program to encourage healing and normal function.

Dental treatment of malocclusion including occlusal adjustment, restorative dentistry, orthodontics, and orthognathic surgery have been advocated for treatment and prevention of TMD to improve the biomechanical efficiency, chewing ability and, in some cases, signs and symptoms of TMD. Seventy-nine studies involving occlusal treatment were reviewed.27,37,48-54 The results of these studies are equivocal
and few conclusions can be arrived at from the studies. The studies had a mean quality score of 0.50 and, thus, may be prone to bias influencing the results. One placebo-controlled RCT studied occlusal adjustment as a treatment of TMJD with a quality score of 0.51 and an NNT of 7. Two placebo controlled RCTs studied occlusal adjustment as a preventive treatment with a quality score of 0.53 and an NNT of 25.

Conclusions that can be drawn from this evidence-based review include;
1. There is insufficient evidence to suggest that any occlusal treatment as reviewed here is more or less effective than placebo in treating TMJD pain.
2. There is also insufficient evidence to suggest that any occlusal treatment is as or more effective than other
rehabilitation treatments in treating TMJD pain.
3. There is also insufficient evidence to support the generalized preventive influence of occlusal adjustment
and orthodontic correction of malocclusion on TMJD development. Since occlusal treatments are typically irreversible treatments and the evidence on its therapeutic or preventive effects on TMJD is insufficient, it is recommended that reversible treatment such as self-care, splints, physical therapy, and cognitive-behavioral therapy be used to initially manage signs and symptoms of TMJD. It is also acknowledged that these occlusal dental treatments can be used successfully to correct a malocclusion or uncomfortable occlusion in a patient with or without TMJD. For example, a patient who reports an uncomfortably high restoration or occlusal prematurities is often treated with an occlusal adjustment as the primary treatment. A patient who develops an open bite from rheumatoid the occlusion. However, since occlusal stability can be affected by
problems in the muscles or joints, it is important to stabilize TMJD signs and symptoms as well as jaw position with reversible treatments prior to considering any irreversible treatments to correct the malocclusion. A jaw position can be evaluated for stability using several methods, including improvement in the signs and symptoms; splint adjustments have not changed in past 2 to 3 months; no changes in TMJ
computed tomography scans in past 6 months; and no increase in incisal edge to incisal edge measurements. Failure to ensure jaw position is stable may result in continued occlusal dysfunction. However, once the muscles, joints, and jaw position are stable, occlusal treatment can proceed with improved confidence that occlusal changes will not occur after the occlusal treatment is completed.

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